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Digitized  by  the  Internet  Archive 

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http://www.archive.org/details/treatiseonregion01binn 


A  TREATISE 

ON 

REGIONAL  SURGERY 

VOLUME  1 

BI  N  N  i  E 


VOLUME  I 

The    Head  —  Branchial    System  —  The 
Thorax — The  Breast  .... 


VOLUME  II 

The  Abdomen  —  The  Genito-Urinary 
System — The  Spine 


VOLUME  III 

The  Upper  Extremity — The  Lower  Ex- 
tremity   


A  TREATISE 


ON 


REGIONAL  SURGERY 


BY  VARIOUS  AUTHORS 


EDITED    BY 

JOHN  FAIRBAIRN  BINNIE,  A.  M.,  C.  M.,  F.  A.  C.  S 

KANSAS  CITY,   MISSOURI 


VOLUME   I 


WITH  351  ILLUSTRATIONS 


PHILADELPHIA 

P.  BLAKISTON'S  SON  &  CO 

1012  WALNUT  STREET 


c^ 


Copyright,  1917,  by  P.  Blakiston's  Son  &  Co. 


rHE     MAPT.E     PRESS    YORK     PA 


PREFACE 


General  surgery  deals  with  certain  principles  of  pathology  and 
therapy  which  apply  to  all  fields  of  the  art,  but  does  not  concern  itself 
with  the  peculiarities  of  disease  and  injury  when  these  afTect  particular 
regions  or  organs.  A  knowledge  of  general  surgery  is  a  sine  qua  non, 
but  once  the  student  is  well  grounded  in  the  principles  of  his  art  it 
becomes  essential  for  him  to  know  its  appHcation  and  to  afford  this 
knowledge  is  the  province  of  Regional  or  Special  Surgery. 

The  aim  of  the  present  work  is  to  present  short  treatises  on  the  in- 
juries and  diseases  of  the  different  regions  of  the  body. 

To  each  of  the  authors  who  kindly  consented  to  contribute  the 
editor  sent  an  estimate  of  the  length  of  the  article  desired  along  with  a 
request  that  the  contents  be  practical .  and  consist  of  the  opinions  of 
the  author  himself  and  not  a  statement  of  what  "he  thought  other 
people  would  think  that  he  ought  to  think."  The  authors  were  further 
invited  to  use  illustrations  wherever  they  deemed  such  necessary  to 
illustrate  their  text  but  not  for  merely  decorative  purposes. 

In  the  following  pages  one  can  judge  how  the  individual  authors 
interpreted  and  carried  out  these  requests,  as  the  Editor  has  not  presumed 
to  interfere  in  the  slightest  degree  with  the  material  contained  in  the 
various  chapters. 

In  a  work  of  this  character  there  is  bound  to  be  some  overlapping. 

When  overlapping  or  repetition  occurs  it  is  interesting  and  instructive 

to  note  the  differences  in  the  views  expressed  by  the  different  authors. 

^     No  apology  is  offered  for  this  repetition — to  the  Editor  it  seems  an 

-     advantage. 

There  was  so  much  difficulty  in  securing  a  suitable  authority  to 
write  a  chapter  on  the  diseases  of  the  brain  that,  rather  than  insult  the 
reader  with  a  piece  of  'hack  work,'  the  Editor  chose  to  omit  it  entirely. 

Dr.  James  E.  Logan  was  good  enough  to  assist  the  Editor  in  obtain- 
ing authors  to  undertake  the  chapters  on  the  Nose,  Pharynx  and  Ear. 
Thanks  arc  due  to  Drs.  R.  M.  Schauffier,  C.  B.  Francisco,  John  G. 


Vi  PREFACE 

Hayden,  H.  S.  Valentine  and  Mrs.  C.  M.  Bossier  for  generous  assist- 
ance in  proof-reading,  etc. 

For  the  plan  of  the  work  the  Editor  is  responsible ;  for  its  execution 
the  responsibility  lies  with  the  Surgeons  of  America,  Britain  and  far  off 
Australia,  who  so  kindly  consented  to  help  him 

J.  F.  B. 


LIST  OF  CONTENTS 


SECTION  I 

Page 

Traumata  of  the  Scalp,  Clarence  A.  Mc Williams,  a.  m.,  m  d.,  f.  a.  c.  s.  .    .    .       i 

SECTION  II 
Diseases  of  the  Scalp,  J.  F.  Binnie,  a,  m,,  c.  m.,  f.  a.  c.  s n 

SECTION  III 

Traumata  of  the  Skull  and  Contents,  James  Hogarth  Pringle,  m.  b.,c.  m.  (Ed.) 

F.  R.  c.  s.  (Eng.) 23 

SECTION  IV 

Development,  J.  F.  Binnie,  a.  m.,  c.  m.,  f.  a.  c.  s 69 

SECTION  V 

Hare-lip  and  Cleft  Palate,  J.  F.  Binnie,  a.  m.,  c.  m.,  f.  a.  c.  s 87 

SECTION  VI 

Congenital  Defects,  J.  F.  Binnie,  a.  m.,  c.  m,  f.  a.  c.  s 107 

SECTION  VII 

Injuries  and  Diseases  of  the  Face  and  Jaw,  J.  E.  Summers,  m.  d.,  f.  a.  c.  s.    .    .    117 

SECTION  VIII 

Operations  for  Trifacial  Neuralgia,  J.  F.  Binnie,  a.  m.,  c.  m.,  f.  a.  c.  s 173 

SECTION  IX 

Operations  upon  the  Jaws,  J.  F.  Binnie,  a.  m.,  c.  m.,  f.  a.  c.  s 177 

SECTION  X 

Diseases  of  the  Buccal  Cavity,  Sir  H.  L.  Maitland,  M.  CH.,  M.  B 183 

vii 


viii  LIST    OF    CONTENTS 

SECTION  XI 

Page 

Injuries  and  Diseases  of  the  Tongue,  Sir  H.  L.  Maitland,  m.  ch.,  m.  b.    .    .    .    197 

SECTION  XII 
Neoplasms  of  the  Tongue,  Sir  H.  L.  Maitland,  m.  ch.,  m.  b 211 

SECTION  XIII 
The  Salivary  Glands,  Sir  H.  L.  Maitland,  M.  CH.,  M.  B 22^ 

SECTION  XIV 
The  Pharynx,  Joseph  L.  Goodale,  a.  m.,  m.  d 239 

SECTION  XV 
The  Nose,  Lee  M.  Hurd,  m.  d.,  f.  a.  c.  s 249 

SECTION  XVI 
The  Ear,  Max  A.  Goldstein,  m.  d.,  f.  a.  c.  s 291 

SECTION  XVII 
The  Neck,  J.  E.  Thompson,  m.  b.,  b.  s.,  f.  r.  c.  s.,  f.  a.  c.  s 321 

SECTION  XVIII 
The  Larynx,  Trachea  and  Bronchi,  Chevalier  Jackson,  m.  d.,  f.  a.  c    s.    .    .   401 

SECTION  XIX 

The  Thyroid,  Charles  H.  Mayo,  a.  m.,  m.  d.,  ll.  d.,  f.  a.  c.  s 475 

SECTION  XX 
The  Parathyroids,  Charles  H.  Mayo,  a.  m.,  m.  d.,  ll.  d.,  f.  a.  c.  s 511 

SECTION  XXI 
The  Thymus,  Charles  H.  Mayo,  a.  m.,  m.  d.,  ll.  d.,  f.  a.  c.  s 529 

SECTION  XXII 

Surgery  of  the  Heart,  Pericardiurh  and  Diaphragm,  Sam  Robinson,  a.  b.,  m.  d., 

F-  A.  c.  s.     .    . 545 

SECTION  XXIII 

The  Breast,  J.  C.  Bloodgood,  b.  sc,  m.  d.,  f.  a.  c.  s 557 

Index 631 


REGIONAL  SURGERY 


THE  HEAD 

SECTION  I 
TRAUMATA    OF   THE    SCALP 

By 
CLARENCE  A.  McWILLIAMS,  A.  M.,  M.  D.,  F.  A.  C.  S. 

New  York 

Anatomy. — The  scalp  is  made  up  of  all  the  soft  parts  covering  the 
bony  vault  of  the  skull.     It  may  be  divided  into  live  layers: 

1.  The  skin,  the  thickest  in  the  body,  is  closely  bound  to  the  galea 
aponeurotica  into  which  the  occipitofrontalis  muscle  is  inserted, 
hence  it  moves  with  these  muscles. 

2.  The  subcutaneous  layer  (or  superficial  fascia)  consists  of  a  large 
number  of  strong  fibrous  bands,  binding  together  the  skin  and 
aponeurosis  and  forming  a  multitude  of  small  compartments, 
containing  lobules  of  fat.  The  blood-vessels  and  nerves  supply- 
ing the  three  layers  of  the  scalp  are  subcutaneous  instead  of 
subaponeurotic,  and  are  so  closely  connected  with  the  fibrous 
partitions  that,  when  divided  in  wounds  of  the  scalp,  they  are  often 
unable  to  contract,  hence  hemorrhage  is  profuse  and  not  liable  to 
stop  spontaneously.  It  is  sometimes  difl&cult  to  clamp  the  vessels 
in  the  dense  fibrous  tissue,  hence  a  suture  ligature  may  be  at 
times  the  best  means  of  stopping  the  -hemorrhage.  The  hair 
bulbs  extend  into  the  subcutaneous  layer  and  are  so  firmly 
attached  that  the  weight  of  the  body  may  be  sustained  by  the 
hair.  Instances  are  numerous  where  the  hair  has  been  caught 
in  the  wheels  of  a  machine,  causing  the  tearing  of  more  or  less 
of  the  scalp  from  the  skull;  avulsion  of  the  scalp. 

3.  The  aponeurotic  layer,  or  galea  aponeurotica,  consists  of  an 
aponeurosis  extending  between  the  anterior  and  posterior  por- 
tions of  the  occipitofrontalis  muscle. 


REGIONAL   SURGERY 

4.  The  subaponeurotic  areolar  layer  consists  of  loose  connective 
tissue  which  allows  considerable  movement  of  the  superficial 
scalp  upon  the  pericranium.  This  looseness  of  attachment 
permits  the  gaping  of  scalp  wounds  and  the  easy  separation  of 
large  flaps  of  scalp  in  injuries,  operations,  scalping  by  Indians  or 
autopsies.  Wounds  of  the  scalp  do  not  gape  unless  the  occipito- 
f  rontalis  or  aponeurosis  be  divided  and  the  greatest  gaping  occurs 
where  the  division  has  been  transverse  to  the  direction  of  the 
muscle  fibers.  Treves  has  called  this  layer  the  "dangerous  area 
of  the  scalp"  because  of  the  wide  and  rapid  spread  of  suppura- 
tion, posteriorly,  as  far  as  the  superior  curved  line,  anteriorly, 
to  the  superciliary  edges  and  laterally  to  or  even  below  the  level 
of  the  zygoma. 

5.  The  pericranium  (or  external  periosteum)  is  very  slightly 
adherent  to  the  bone  beneath,  except  at  the  sutures  and  foramina 
where  it  is  continuous  with  the  dura;  hence  the  danger  of  in- 
flammation of  the  pericranium  extending  to  the  dura.  Owing 
to  the  attachment  of  the  pericranium  to  the  sutural  membrane, 
hematomata  and  abscesses  are  usually  limited  to  the  area  of  one 
bone.  In  extensive  scalp  wounds,  the  pericranium  may  be 
widely  stripped  from  the  bone  beneath  without  causing  necrosis 
of  the  bone  which  derives  its  blood  supply  from  the  vessels  of  the 
diploe  and  dura. 

The  vessels  of  the  scalp  are  large,  rendering  the  living  of  very 
large  flaps  almost  certain.  The  arteries  are  subcutaneous, 
instead  of  being  subfascial,  as  is  the  case  in  other  situations  in 
the  body.  They  are  arranged  in  pairs:  two  anterior,  the  frontal 
and  supraorbital,  both  branches  of  the  ophthalmic;  two  lateral, 
anterior  and  posterior  temporals,  both  branches  of  the  temporal, 
itself  a  branch  of  the  external  carotid;  two  posterior,  the  posterior 
auricular  and  occipital,  each  a  branch  of  the  external  carotid. 
All  the  arteries  go  from  base  to  apex,  freely  anastomose  and 
form  a  complete  network. 
The  veins  of  the  scalp  are  of  three  classes: 

1.  Superficial,  accompanying  the  corresponding  arteries  in  the 
subcutaneous  tissue. 

2.  Diploic,  traversing  the  diploe,  which  is  the  spongy  osseous  tissue 
between  the  two  tables  of  the  skull.  These  veins  communicate 
with  the  venous  sinuses  internally,  and  the  superficial  veins 
externally  by  means  of  the  emissary  veins. 


TRAUMATA   OF   THE    SCALP  3 

3.  Emissary,  which  pass  through  foramina  in  the  skull  and  establish 
communication  between  the  veins  of  the  scalp  and  the  sinuses. 
The  three  most  important  emissary  veins  are: 

(a)  The  vein  passing  through  the  mastoid  foramen  and  connect- 
ing the  lateral  sinus  with  the  occipital  or  posterior  auricular 
vein.  Leeches  applied  behind  the  ear  may  thus  abstract 
blood  directly  from  the  intracranial  circulation. 

(b)  The  vein  traversing  the  posterior  condylar  foramen  and 
connecting  the  sigmoid  sinus  with  the  deep  veins  at  the  back 
of  the  neck. 

(c)  The  vein  which  passes  through  the  parietal  foramen  to  reach 
the  superior  longitudinal  sinus. 

There  are  also  many  minute  veins  which  connect  the  veins  of  the 
scalp  with  the  veins  of  the  diploe.  Through  the  emissary  veins 
infections  of  the  scalp  may  be  carried  to  the  bones,  sinuses,  meninges 
and  brain.  The  anastomosis  between  the  angular  and  supraorbital 
veins  at  the  inner  angle  of  the  orbit,  brings  about  a  free  communication 
between  the  extra-  and  intracranial  circulation,  since  the  supraorbital 
vein  through  the  ophthalmic  is  a  tributary  of  the  cavernous  sinus.  If 
there  were  no  emissary  veins,  injuries  and  diseases  of  the  scalp  would 
lose  half  their  seriousness  (Treves). 

The  lymphatics  of  the  scalp  form  three  distinct  groups: 

(a)  The  anterior  parietal  and  frontal  empty  into  the  parotid  nodes. 
Some  of  the  frontal  vessels  join  the  lymphatics  of  the  face  and 
end  in  the  submaxillarly  ganglia. 

(b)  The  posterior  parietal  empty  into  the  mastoid  nodes. 

(c)  The  occipital  lymphatics  pass  directly  back  and  empty  into  the 
suboccipital  ganglia,  although  a  few  may  reach  the  ganglia 
under  the  sternomastoid. 

Wounds. — Scalp  wounds  are  ordinarily  classified  as: 

(a)  Contused. 

(b)  Incised. 

(c)  Punctured. 

(d)  Lacerated. 

Contusions  may  be  made  by  either  glancing  or  direct  blows,  which 
produce  hemorrhages  in  the  various  layers.  The  hematomata  caused 
by  direct  blows  are  usually  small,  hard,  circumscribed,  subcutaneous 
swellings,  which  can  be  moved  with  the  scalp.  In  the  case  of  glancing 
blows,  hematomata  into  the  deeper  layers  are  produced  by  the  tearing 
away  of  the  scalp  from  its  subaponeurotic  attachments  (subaponeu- 


4  REGIONAL   SURGERY 

rotic  hematoma)  or  of  the  pericranium  from  the  bone  beneath  (sub- 
pericranial  hematoma).  Subaponeurotic  hematomata  may  be  large 
in  extent,  due  to  the  blood  dissecting  along  the  areolar  tissue  between 
the  aponeurosis  or  muscles  and  the  pericranium.  Absorption  of  the 
blood  is  often  very  slow.  Near  the  periphery  of  the  hematoma  the 
blood  soon  clots  and  the  tissues  are  densely  infiltrated;  thus  the  soft 
center  of  the  hematoma  is  surrounded  by  a  hard,  elevated  rim.  To 
the  examining  finger  the  soft  center  of  the  hematoma  feels  like  a  de- 
pression in  the  bone  and  may  mislead  even  the  most  experienced. 

In  favorable  cases  firm  pressure  with  the  finger  may  make  the  hard 
rim  disappear  and  show  the  skull  to  be  smooth  and  free  from  depression. 

Non-absorption  of  a  hematoma  may  result  in  the  formation  of  a 
blood  cyst. 

Occasionally  the  skin  over  the  swelling  becomes  gradually  thinned 
out  and  may  ultimately  give  way.  In  other  cases,  particularly  when 
the  skin  has  been  broken,  suppuration  may  take  place. 

Subpericranial  Hematomata. — With  advancing  years  the  peri- 
cranium loses  in  large  part  its  abundant  vascular  attachments  to  the 
skull  and  thus,  while  subpericranial  hematomata  are  common  in  infants, 
they  become  less  and  less  common  as  age  advances.  The  extravasation 
is  usually  limited  by  the  sutures  and  does  not  extend  beyond  the  par- 
ticular bone  over  which  it  first  occurred.  The  mistaken  diagnosis  of  a 
depressed  fracture  is  more  common  here  than  in  the  subaponeurotic 
variety,  for  absorption  of  the  blood  may  fail  (forming  a  blood  cyst) 
and,  around  the  thickened  edges,  the  elevated  pericranium  may  produce 
a  rim  of  new  bone.  The  absence  of  signs  of  cerebral  compression,  when 
the  bone  in  the  center  of  the  swelling  is  pressed  upon,  implies  that  the 
case  is  one  of  subpericranial  hematoma,  rather  than  one  of  depressed 
fracture.  In  both  the  subaponeurotic  and  subpericranial  hematomata, 
if  a  large  arterial  vessel  be  torn,  the  tumor  may  pulsate  but  this  is 
rare.  New  bone  formed  in  a  hematoma  may  persist  and  form  a  bony 
protuberance,  an  osteoma  of  the  skull. 

Treatment  of  Hematomata. — If  the  skin  be  broken,  the  first  neces- 
sity is  careful  disinfection  of  the  scalp  over  the  swelling,  particular 
attention  being  paid  to  the  wounded  surface.  It  is  safest  to  clip  the 
hair  short  and  then,  without  any  previous  washing,  to  disinfect,  by 
the  application  of  tincture  of  iodine,  the  inside  of  the  wound  and  then 
the  surrounding  scalp.  To  limit  the  spread  of  the  effusion,  pressure 
should  be  applied  at  the  earliest  moment  after  the  injury  by  the 
application  of  an  elastic  bandage  over  a  small  mass  of  cotton  wool  which 


TRAUMATA   OF   THE    SCALP  5 

somewhat  overlaps  the  hematoma.  For  24  or  48  hours  it  is  wise  to 
apply  an  ice  bag  over  the  pressure  bandage  which  may  help  to  limit 
the  effusion.  Ice  cold  should  not  be  used  longer  than  this  time,  since  it 
lowers  the  vitality  of  the  tissues. 

If  absorption  goes  on  steadily,  pressure  may  be  kept  up  until  all 
the  blood  is  absorbed;  this  may  require  two  weeks  or  more.  If  absorp- 
tion comes  to  a  standstill  despite  the  above  treatment,  the  central 
portion  of  the  swelling  may  remain  fluid  and  a  blood-cyst  form.  In 
such  cases  the  cure  may  be  hastened  by  aspirating  the  liquid  blood  by 
means  of  a  large-sized  needle,  after  very  careful  sterilization  of  the 
site  of  puncture.  If  it  is  impossible  to  withdraw  the  fluid  through  the 
needle  on  account  of  its  thickness,  it  may  be  evacuated  through  a  very 
small  incision  or  puncture,  at  the  same  time  removing  any  coagula 
with  a  sharp  spoon.  The  cyst  should  not  ordinarily  be  drained  for 
fear  of  infection.  In  some  few  cases  the  fluid  may  re-accumulate,  and 
in  such  a  condition  it  may  be  necessary  to  insert  a  small  rubber  drainage 
tube  through  a  small  incision  in  the  most  dependent  portion  of  the  cyst. 
Absolute  asepsis  must  be  most  carefully  carried  out. 

Cephal-hematoma. — This  is  to  be  distinguished  from  a  caput 
succedaneum,  which  latter  is  present  at  the  time  of  birth  and  is  a  serous 
infiltration  of  the  superficial  structures  of  the  scalp,  due  to  venous  stasis. 
It  corresponds  in  position  to  the  external  os  and  disappears  in  two 
or  three  days.  A  caput  succedaneum  does  not  conform  in  outline  to 
one  of  the  bones  as  does  a  cephal-hematoma;  it  can  be  pitted  on  pressure 
and  does  not  fluctuate. 

A  cephal-hematoma  is  a  subpericranial  effusion  of  blood,  distinctly 
confined  by  the  boundaries  of  one  of  the  cranial  bones,  usually  the 
parietal,  more  rarely  the  occipital  bone.  It  occurs  about  once  in 
200  births  and  may  be  bilateral.  Usually  two  or  three  days  after 
delivery  a  swelling  develops,  rapidly  increases  in  size  and  presents  the 
signs  of  a  cystic  tumor. 

A  cephal-hematoma  is  due  to  the  temporary  indentation  of  a  bone, 
causing  a  tearing  away  of  the  bone  from  its  highly  vascularized  peri- 
cranium, or  by  the  overlapping  of  the  bones  of  the  skull,  causing  injury 
to  the  blood-vessels.  The  pericranium  may  subsequently  produce 
new  bone,  giving  rise  to  a  peculiar  crackling  or  crepitus  over  the  surface 
of  the  tumor.  Gushing  mentions  the  rare  occurrence  of  extradural 
cephal-hematoma  without  any  subpericranial  effusion.  This  is  a  true 
hematoma  under  each  parietal  bone.  In  serious  injuries,  therefore,  he 
says  it  is  possible  to  have  three  layers  of  extravasation,  subpericranial, 


6  REGIONAL   SURGERY 

extradural  and  subdural,  the  last  being  due  to  rupture  of  cortical 
vessels. 

Anything  which  causes  congestion,  such  as  crying  or  straining,  or 
the  venous  stasis  produced  by  intracranial  hemorrhage,  will  tend  to 
increase  the  swelling  markedly.  Cephal-hematomata  usually  last  from 
one  to  two  weeks,  when  they  begin  to  subside.  In  rare  cases  a  cystic 
condition  may  result,  producing  a  swelling  which  may  last  through 
Hfe.  Occasionally  the  clot  becomes  infected,  giving  rise  to  an  abscess 
which  may  lead  to  necrosis  of  bone  and  intracranial  suppuration. 

Diagnosis  of  Cephal-hematomata. — This  is  ordinarily  easy  even  if, 
as  is  unusual,  the  swelling  is  present  at  birth  and  is  surrounded  by  a 
caput  succedaneum,  which  is  still  more  rare.  A  caput  succedaneum 
rapidly  subsides  while  a  cephal-hematoma  increases  in  size  and  persists 
for  at  least  several  weeks.  A  spurious  meningocele  may  have  the 
same  position  but  it  pulsates  with  cardiac  and  respiratory  move- 
ments, and  is  reducible,  as  is  also  a  sinus  pericranii,  which  is  usually 
situated  in  the  middle  line. 

Treatment  of  Cephal-hematomata. — Cleanliness  and  moderate 
pressure,  applied  by  means  of  a  bandage,  usually  suffice  but  if  after 
two  weeks  the  swelling  does  not  diminish,  operation  becomes  advisable 
to  avoid  the  danger  of  subsequent  infection  or  the  production  of  a 
permanent  deformity.  After  shaving  the  head  and  disinfecting  with 
tincture  of  iodine  make  a  small  vertical  incision  at  the  lowest  part  of 
the  swelling.  The  injection  of  a  few  drops  of  a  local  anesthetic 
(novocaine  2  per  cent.),  renders  the  incision  painless.  By  pressure  or 
by  the  use  of  a  curette,  evacuate  the  blood,  both  clotted  and  liquid. 
Neither  drainage  nor  sutures  should  be  used.  Apply  a  dressing  under 
moderate  pressure. 

Pneumatocele  cranii  is  a  rare  gaseous  tumor  which  appears  under 
the  scalp,  either  in  connection  with  the  air-containing  mastoid  cells  or 
the  frontal  sinuses.  There  is  often  a  previous  history  of  direct  violence 
or  of  infection  by  which  part  of  the  thin  layer  of  bone  under  the  peri- 
cranium has  been  destroyed  without  injury  to  the  membrane  itself. 
The  pericranium  is  detached  and  ballooned  out  by  an  increase  in 
pressure  transmitted  through  the  Eustachian  tube  to  the  mastoid  cells 
or  through  the  infundibulum  to  the  frontal  sinuses. 

The  affection  may  be  bilateral  and  is  easy  of  recognition,  owing  to 
the  tympanitic  tumor.  The  surgical  treatment  consists  in  the  free 
opening  of  the  tumor  and  the  denudation  of  its  walls  so  as  to  form  fresh 


TEAUMATA   OF   THE    SCALP  7 

surfaces,  which  it  is  hoped  will  subsequently  adhere  under  the  pressure 
of  a  snug  bandage. 

Sinus  pericranii  (Stromeyer)  is  a  collection  of  fluid  blood,  pro- 
ducing a  cystic  tumor,  situated  usually  near  the  mid-line  of  the  skull 
and  under  the  pericranium.  It  is  often  of  traumatic  origin  and  the 
resulting  extracranial  blood  sac  communicates  with  the  longitudinal 
sinus  through  a  canal  in  the  skull.  The  swelling  is  reducible  on  pres- 
sure, is  rarely  larger  than  a  walnut,  and  is  soft  and  elastic.  The  size 
and  tension  of  the  swelling  are  increased  by  coughing  or  straining. 

Treatment  of  Sinus  Pericranii. — If  the  affection  is  the  result  of 
increased  intracranial  pressure  due  to  a  brain  tumor,  removal  of  the 
tumor  or  a  decompression  operation  may  cause  its  disappearance.  If 
due  to  other  causes  the  sac  should  be  opened  and  the  canal  through  the 
skull  obliterated  by  plugging  with  Horsley's  wax  or  a  fragment  of 
muscle  or  by  crushing  its  walls  together  with  rongeur  forceps. 

Meningocele  spuria  or  cephalo-hydrocele  traumatica  (Bergmann) 
is  never  the  result  of  injuries  of  the  soft  parts  of  the  head  alone,  so  will 
not  be  considered  here. 

Wounds  of  the  Scalp. — While  the  scalp  may  be  the  site  of  ordinary 
incised  and  punctured  wounds,  yet  contused  wounds  are  much  more 
common.  If  a  hand  wearing  a  well-fitting  kid  glove  is  struck  with  a 
blunt  instrument  the  glove  splits  and  gives  the  appearance  of  having 
been  cut — in  the  same  way  a  blow  from  a  blunt  instrument  may  cause 
sphtting  of  the  scalp,  the  result  being  practically  a  combination  of 
incised  and  contused  wounds.  Owing  to  its  loose  connection  with  the 
skull  the  scalp  may  be  partially  or  completely  torn  away.  The  art  of 
scalping  was  perfected  by  the  Indians  but  in  modern  times  the  avulsion 
of  the  scalp  is  most  commonly  the  result  of  the  hair  being  caught  in 
rapidly  moving  machinery.  A  sliding  blow  sustained  in  a  fall  may  rub 
the  scalp  off  the  bone  and  at  the  same  time  grind  dirt  into  all  parts  of 
the  wound.  It  must  be  remembered  that  when  a  person  falls  on  to 
the  ground  from  a  rapidly  moving  conveyance  he  hits  the  ground  not 
only  with  the  force  of  gravity  but  with  the  horizontal  momentum 
communicated  to  him  by  the  vehicle;  thus  he  not  only  hits  the  ground 
but  scrapes  or  slides  along  it  with  suflacient  friction  to  produce  much 
heat.  The  result  may  be  a  contusion,  laceration  and  burning  of  the 
scalp. 

Hemorrhage  may  be  very  free  even  in  comparatively  superficial 
wounds  as  has  been  already  explained.  When  there  is  much  laceration 
the  bleeding  is  liable  to  be  less  than  when  the  wound  is  clean  cut. 


8  REGIONAL   SURGERY 

Punctured  wounds  are  not  so  common.  Blows  which  produce  them 
are  more  likely  to  be  glancing  and  to  slice  off  a  flap  of  scalp.  The  bony 
skull  may  likewise  be  penetrated.  The  tract  should  be  disinfected 
by  carrying  in  tincture  of  iodine  on  a  small  cotton  swab  and  drained 
with  a  slip  of  rubber  tissue.  On  the  slightest  sign  of  any  deep  sup- 
puration, the  tract  should  be  laid  open  and  packed.  A  knife  blade 
introduced  into  the  temporal  region  may  be  broken  off  above  the 
zygoma  and  produce  serious  hemorrhage.  Very  exceptionally  ligation 
of  the  external  carotid  may  be  required  to  stop  the  resulting 
hemorrhage. 

More  or  less  laceration  and  bruising  are  commonly  associated  with 
scalp  wounds,  in  fact  a  blow  with  a  blunt  instrument  is  the  commonest 
cause  of  what  is  apparently  an  incised  wound  of  the  scalp. 

Treatment  of  Scalp  Wounds. — In  all  scalp  wounds  there  are  three 
points  which  have  to  be  attended  to: 

1.  The  arrest  of  hemorrhage. 

2.  The  disinfection  of  the  wound. 

3.  The  union  of  the  cut  edges. 

According  to  their  severity  scalp  wounds  may  be  divided  into  three 
groups  with  respect  to  treatment: 

1.  Those  in  which  the  wound  passes  only  through  the  subcutaneous 
tissues. 

2.  Those  in  which  either  the  aponeurosis  or  the  pericranium  or  both 
are  divided. 

3.  Those  in  which  considerable  portions  of  scalp  are  detached. 
Treatment  of  superficial  wounds.     Remove  the  hair  from  around 

the  wound  by  clipping  or  dry  shaving.  Remove  oil  or  grease 
by  washing  with  benzine.  After  the  benzine  has  evaporated 
paint  the  wound  and  the  surrounding  skin  with  tincture  of  iodine. 
Remove  all  visible  foreign  matter  from  the  wound.  Close  the  wound 
with  interrupted  sutures  of  horse-hair  or  silkworm  gut.  Hemostasis 
may  be  secured  by  the  pressure  of  a  bandage  on  the  dressings.  All 
sutures  should  be  removed  by  the  fifth  day  or  earlier  if  they  are  causing 
irritation.  If  the  wound  becomes  infected  all  stitches  must  be  removed 
and  it  must  be  treated  as  an  open  wound. 

When  the  occipito-frontalis  muscle  or  the  aponeurosis  is  divided, 
especially  if  the  division  is  transverse,  there  is  considerable  gaping  of 
the  wound.  If  hemorrhage  is  severe  enough  to  interfere  with  proper 
disinfection  of  the  wound  it  may  be  controlled  by  a  rubber  band  or 
tube  passed  two  or  three  times  around  the  skull  from  the  glabella  to 


TRAUMATA    OF   THE    SCALP  9 

beneath  the  occipital  protuberance.     This  tourniquet  may  be  removed 
after  dressings  have  been  appHed  to  the  wound. 

Permanent  hemostasis  may  be  secured  by  ligatures  usually  applied 
as  stitches  around  the  vessels  or  by  the  pressure  of  a  bandage  over  the 
dressings  after  the  wound  has  been  closed  with  sutures.  When  there 
is  much  laceration  of  the  edges  of  the  wound  these  may  be  pared  with 
knife  or  scissors.  If  the  bone  is  soiled  it  may  be  advisable  to  chisel 
off  a  thin  layer  of  its  surface,  taking  care,  however,  not  to  open  the 
diploe,  and  then  to  disinfect  it  with  iodine  or  with  pure  carbolic  acid, 
neutralized  immediately  with  alcohol.  The  wound  is  closed  with  inter- 
rupted sutures,  preferably  of  silkworm  gut;  these  should  be  introduced 
as  far  apart  as  possible  and  should  involve  the  aponeurosis  and  peri- 
cranium, if  these  structures  are  divided.  Except  in  very  dirty  wounds 
drainage  is  unnecessary;  when  it  is  necessary  it  may  be  provided  by  the 
introduction  of  narrow  strips  of  rubber  tissue.  All  scalp  wounds 
ought  to  be  carefully  watched  so  as  to  anticipate  the  spread  of  infection. 
If  the  scalp  has  been  torn  away  from  the  head  and  has  been  promptly 
recovered,  it  may  be  replaced,  after  cleansing  both  it  and  the  bed  from 
which  it  was  torn  with  a  solution  of  tincture  of  iodine,  one-quarter  the 
official  strength.  The  flap  may  be  held  in  position  by  a  few  sutures. 
Even  when  the  re-implantation  is  fairly  successful  parts  of  the  flap  often 
necrose,  necessitating  subsequent  skin  grafting. 

Infections. — Diffuse  cellulitis  of  the  subaponeurotic  layer  is  one  of 
the  commonest  results  of  scalp  wounds,  especially  those  which  are 
particularly  soiled  and  those  which  are  inadequately  cleansed  and 
disinfected.  Deep-closed  wounds  may  appear  to  be  healing  without 
reaction  for  two  or  three  days  when  the  incidence  of  tenderness  and 
edema  of  the  tissues  with  fever  and  increased  rapidity  of  the  pulse 
show  the  presence  of  infection.  Unless  the  wound  is  opened  suffi- 
ciently to  let  out  the  inflammatory  products,  serious  results  may  occur. 
Infection  in  the  loose  aponeurotic  layer,  having  no  natural  outlet,  may 
spread  widely.  The  pericranium,  even  if  it  be  not  torn  by  the  original 
injury,  becomes  involved,  sloughs  away,  and  the  bone  beneath  is  liable 
to  become  infected.  The  resulting  osteomyelitis  may  affect  only  the 
outer  table  of  the  skull  or  it  may  invade  the  diploe  and  inner  table  and 
large  areas  of  the  calvarium  may  necrose  and  sequestrate.  Even  in 
less  severe  processes,  infection  may  travel  through  the  diploic  vessels 
to  involve  the  cranial  sinuses  or  infect  the  cerebro-spinal  fluid.  If  the 
infection  has  spread,  free  vertical  incisions  must  be  made  through  the 
occipito-frontalis    aponeurosis    and    drainage    tubes    inserted.     The 


lO  REGIONAL   SURGERY 

incisions  should  extend  beyond  the  inflammatory  area.  Boric  fomen- 
tations should  be  applied,  and  in  bad  cases  irrigation  may  be  employed, 
the  head  and  neck  being  surrounded  by  a  mackintosh  in  such  a  way  as 
to  carry  off  the  fluid  without  soiling  the  bed.  When  the  inflammation 
has  begun  to  subside,  the  irrigation  may  be  discontinued  and  wet 
antiseptic  dressings  substituted  for  it. 

Subpericranial  abscesses  are  usually  limited  to  the  surface  of  a  single 
cranial  bone,  due  to  the  pericranial  attachments.  They  are  often  due 
to  the  secondary  infection  of  a  cephal-hematoma,  from  operative  inter- 
ference or  from  a  hematogenous  source.  These  abscesses  are  often 
secondary  to  osteomyelitis,  particularly  mastoid  disease. 

In  extensive  infections  of  the  scalp,  a  large  defect  may  result.  The 
healing  of  such  a  defect  may  be  hastened  materially  by  skin  grafting. 

Erysipelas  was  formerly  a  very  common  complication  of  even  small 
scalp  wounds.  When  the  disinfection  of  the  scalp  wound  is  thoroughly 
performed,  it  is  a  very  rare  complication.  Erysipelas  of  the  scalp  does 
not  manifest  itself  as  elsewhere  in  the  body.  On  account  of  the  density 
of  the  subcutaneous  tissues,  the  usual  sharp  demarcation  with  redness 
and  elevation  of  the  skin  are  largely  absent.  Hence  it  may  not  be 
recognized  until  its  edge  reaches  the  forehead.  The  gravity  of  erysip- 
elas in  this  region  is  due  to  the  possibihty  of  the  inflammation  spreading 
to  the  meninges  or  to  the  diploic  veins.  The  treatment  does  not  differ 
from  that  of  erysipelas  elsewhere  in  the  body. 


SECTION  II. 
DISEASES  OF  THE  SCALP 

By 
JOHN  FAIRBAIRN  BINNIE,  A.  M.,  C.  M.,  F.  A.  C.  S. 
Kansas  City,  Mo. 

The  common  infections  of  the  scalp  have  been  suflSciently  discussed 
in  the  chapter  on  Traumatisms. 

Furuncles  and  carbuncles  are  frequent  about  the  junction  of  the 
scalp  and  neck.  Such  lesions  as  eczema,  seborrhoea,  favus,  tinea,  etc., 
hardly  belong  to  a  work  on  surgery. 

Tuberculous  ulcers  of  the  scalp  may  occur  secondarily  to  lesions  of 
the  skull.     Lupus  is  rare  except  as  an  extension  from  the  face. 

Syphilitic  Lesions  of  the  Scalp. — Secondary  macules,  papules  and 
pustules  are  common.  When  they  are  situated  along  the  hair  margin 
above  the  forehead  they  constitute  the  "corona  veneris." 

Alopecia  syphilitica  belongs  to  the  early  secondary  stage  of  the 
disease.  The  hair  may  come  out  in  patches  but  usually  is  merely 
thinned;  it  rarely  leads  to  baldness  and  is  a  much  over-rated  symptom 
of  syphilis. 

Gummata. — In  the  later  stages  of  syphilis,  nodules  may  appear  in 
the  scalp  especially  in  the  forehead.  These  nodules  may  be  flat  or 
prominent,  have  a  bluish-red  surface  and  are  arranged  in  groups. 
They  are  painless  and  have  a  marked  tendency  to  break  down  leaving 
punched  out,  dirty  ulcers  which  spread  peripherally.  The  disease 
spreads  by  the  breaking  down  of  fresh  nodules  near  the  original  ulcer 
which  tends  to  heal;  hence  the  serpiginous  form  of  the  ulcer  which 
permits  a  diagnosis  being  made  at  a  glance.  Konig  draws  attention 
to  the  fact  that  large  ulcers  with  smooth  floors  of  granulation  tissue 
may  develop  on  the  basis  of  the  multiple  skin  nodules,  be  resistant  to 
almost  any  treatment  and  show  a  marked  tendency  to  hemorrhage 
because  of  their  rich  blood  supply. 

Tumors  of  the  Scalp. — Hertzler  remarks,  "the  cranial  region  may 
be  called  the  oncological  museum  of  the  body,  since  almost  every  known 
tumor  may  be  encountered  here  either  as  a  primary  growth  or  as  a 
metastasis  of  a  growth  in  a  distant  organ." 


12  REGIONAL   SURGERY 

Wens ;  Atheromata ;  Sebaceous  Cysts. — Owing  to  the  plugging  of 
its  duct,  a  sebaceous  gland  becomes  distended  with  a  collection  of 
cheesy  sebaceous  material.  Connective  tissue  around  the  gland 
becomes  condensed  into  a  capsule  for  it.  Thus  a  cyst  forms  in  the 
skin;  only  by  extension  does  it  invade  the  subcutaneous  tissues.  The 
tumors  vary  in  size  from  a  pea  to  an  orange — usually  they  are  about  the 
size  of  a  marble.  The  skin  covering  them  is  smooth  and  hairless.  The 
tumors  are  never  attached  to  the  skull,  thus  differing  from  meningo- 
celes and  they  are  usually  found  in  adults,  thus  differing  from  dermoids 
which  are  more  common  in  adolescents.  Wens  grow  slowly  and  are 
painless;  occasionally  they  become  infected  and  result  in  abscess  forma- 
tion. Unless  the  sac  of  the  cyst  is  destroyed  by  the  inflammation  or 
removed  by  the  surgeon,  the  inflammation  is  likely  to  be  recurrent. 
Occasionally  an  epithelioma  develops  on  the  basis  of  an  irritated  wen. 

Treatment. — {A)  Make  an  incision  into  the  cyst  nearly  as 
long  as  the  diameter  of  the  tumor.  Seize  the  cyst  wall  with  a 
strong  forceps  (hemostat)  and  with  a  twisting  motion  pull  out 
the  whole  sac. 

Close  the  wound  with  a  few  sutures. 

{B)  Expose  the  tumor  through  crescentic  incisions  and  dissect  it 
out  without  opening  it. 

Dermoid  cysts  are  of  congenital  origin,  are  lined  by  a  membrane 
allied  to  skin  and  contain  oily  material,  epithelial  detritus  and  hair. 
The  cysts  arise  at  the  lines  of  union  of  the  developing  cranium  and 
hence  are  most  common  at  the  temples,  root  of  nose,  orbit  or  over  the 
fontanelles.  The  tumors  are  smooth  and  hemispherical  swellings  with 
fixed  base  but  the  skin  is  movable  over  them.  The  bone  under  and 
around  their  base  may  be  deficient  or  absent.  The  tumors  may 
pulsate  but  they  do  not  disappear  on  pressure.  While  dermoids  are 
always  congenital  they  may  not  be  noticed  until  the  second  or  third 
year  and  are  apt  to  develop  rapidly  about  the  time  of  puberty. 

Treatment. — Excision  if  necessary. 

Lipomata. — Fatty  tumors  of  the  scalp  are  rare  and  when  they  do 
occur  they  are  usually  situated  in  the  frontal  or  temporal  regions. 
They  lie  under  the  aponeurosis,  are  never  adherent  to  the  skin  and 
form  flattened,  soft,  elastic  prominences.  Owing  to  a  thickening  of  the 
periosteum  round  a  lipoma,  it  appears  on  palpation  to  lie  in  a  depression 
in  the  skull.  Occasionally  when  a  lipoma  is  large  it  may  so  drag  on  its 
base  as  to  form  a  distinct  pedicle. 

Treatment  when  required  is  excision. 


DISEASES    OF    THE    SCALP  I3 

Papillomata ;  Warts  ;  Moles. — Pigmented  nevi  are  common  on  the 
scalp.  Pigmented  or  hairy  moles  and  warts  are  sometimes  the  starting- 
point  of  melano-sarcoma  and  of  epithelioma  respectively.  It  has  been 
observed  that  when  pigmented  moles  are  multiple  they  are  less  liable 
to  malignant  degeneration  than  when  single  and  also  that  a  mole  on  the 
temple  is  to  be  looked  on  with  more  suspicion  than  one  situated  else- 
where on  the  scalp. 

Often  no  treatment  is  required  but  when  there  is  much  disfigurement 
or  irritation,  or  where  subsequent  malignancy  is  dreaded,  excision  may 
be  obligatory. 

In  fiat  moles  application  of  carbon-dioxide  snow  may  be  curative 
and  leave  little  or  no  scar.  In  hairy  moles  Pusey  has  destroyed 
the  hair  by  exposure  to  the  X-rays  and  then  removed  the  pigmented 
tissues  with  the  snow. 

Carbon-dioxide  gas  may  be  obtained  in  tanks.  Permit  a  spray  of 
the  gas  to  play  into  a  bag  of  chamois  leather.  Snow  is  at  once  formed. 
Put  the  snow  into  a  cylindrical  mould  and  tamp  it  down  firmly  with  a 
stick,  or  pestle.  Remove  the  firm  candle  of  snow  from  the  mould  and 
trim  it  to  the  desired  shape  with  a  knife.  Apply  the  snow  candle  with 
moderate  firmness  for  a  few  seconds  to  the  part  to  be  treated.  The 
application  may  require  to  be  repeated  two  or  three  times  at  intervals 
of  about  one  week. 

Cutaneous  horns  may  arise  from  a  wart  or  a  sebaceous  cyst  and 
consist  of  stratified  layers  of  horny  epithelium.  They  may  be  multiple, 
are  very  disfiguring  and  may  undergo  malignant  changes.  Treatment 
is  excision. 

Fibroma  molluscum  when  involving  the  scalp  is  usually  merely  a 
part  of  a  more  generalized  process.  True  fibromata  occasionally  appear 
on  the  scalp  and  may  be  of  very  large  size. 

Scar  keloid  is  a  form  of  fibroma  arising  from  a  pre-existing  scar. 
It  is  very  common  in  negroes. 

While  the  treatment  of  fibromata  is  excision  it  is  practically  useless 
to  excise  scar  keloids  because  of  their  tendency  to  recur  in  a  more 
extensive  form. 

Elephantiasis  Nervorum. — Plexiform  neuroma  has  its  favorite  site 
in  the  temporo-frontal  region.  It  is  usually  part  of  a  generalized 
neurofibromatosis.  The  tumor  usually  appears  in  young  adult  life; 
often  its  starting-point  is  a  pre-existing  fibroma  molluscum  or  a  mole. 
"It  is  first  evidenced  by  a  thickening  and  loosening  of  the  subcutaneous 
tissues,  so  that  the  scalp  may  be  moved  with  greater  readiness  upon  the 


14  REGIONAL   SURGERY 

skull.  Finally,  of  its  own  weight,  it  begins  to  sag,  drawing  down  the 
outer  canthus  and  crowding  the  pinna  downward  until  the  ear  stands 
out  perpendicular  to  the  skull,  or  becomes  buried  altogether  under  the 
hanging  folds  of  the  tumor  mass,  which  may  even  reach  as  low  as  the 
shoulder.  The  hair  over  it  becomes  coarse  and  the  skin  roughened;  it 
is  difl&cult  to  keep  the  mass  clean,  owing  to  its  folds  and  creases;  ulcera- 
tions may  result,  and  in  advanced  cases,  with  involvement  of  the 
eyelids,  there  is  particular  risk  of  losing  the  globe  from  suppuration. 
The  tumors  are  painless  and  when  uncomplicated  by  infection  or 
degeneration — for  they  may  become  sarcomatous — may  be  carried  for 
years,  though  reaching  an  enormous  size. 

Pathologically  they  are  made  up  of  a  snarl  of  nerve  fibers  whose 
perineural  sheaths  have  become  greatly  and  irregularly  thickened  from 
an  increase  of  fibrous  tissue.  The  plexiform  meshwork  is  encased  in  a 
loose,  succulent,  fibrous  tissue,  which  for  a  long  time  led  investigators 
to  overlook  the  important  part  played  by  the  nerves  themselves  in  the 
make-up  of  these  tumors. 

Their  recognition  is  not  difficult,  and  once  seen  and  handled  they  are 
never  forgotten.  The  loose,  flaccid  tissue  with  its  contained  tangle  of 
irregularly  lobulated,  cord-like  masses  has  been  likened  to  the  feel  of 
an  atrophic  and  pendulous  mamma.  The  diagnosis  is  easy  even  in  the 
absence  of  other  skin  lesions  common  to  the  disease.  Unless  too  far 
advanced  or  too  widespread,  their  treatment  should  consist  of  early 
removal.  They  rarely  if  ever  extend  below  the  aponeurotic  membrane 
and  may  be  completely  extirpated.  The  chief  dangers  lie  in  the 
possibility  of  infection — for  the  surface  may  be  hard  to  render  aseptic— 
and  in  hemorrhage,  particularly  if  only  a  partial  removal  can  be  at- 
tempted at  one  sitting,  since  they  are  apt  to  be  vascular  and  the 
vessels  in  the  spongy  tissues  will  not  hold  clamps.  Cases  have  been 
reported  by  Billroth  and  others  in  which  a  great  number  of  separate 
operations  were  undertaken  before  complete  removal  was  accomplished." 
(Gushing,  Keen's  Surg.) 

Angioma  simplex;  port-wine  stain;  telangiectatic  nevus  is  a  con- 
genital lesion  composed  of  dilated  capillaries  and  small  blood-vessels. 
When  entirely  capillary  it  may  cause  no  deformity  except  that  due  to 
its  color  but  when  larger  vessels  are  present,  whether  arteries  or  veins, 
a  tumor  of  more  or  less  prominence  is  in  evidence.  The  lesion  presents 
all  gradations  of  color  from  bright  red  to  blue  and,  if  arterial,  may 
pulsate.  While  congenital  the  lesions  are  usually  more  prominent 
after  four  or  five  weeks  than  at  birth. 


DISEASES    OF   THE    SCALP  1 5 

Nevi  may  be  so  small  as  to  be  almost  invisible  or  may  involve  large 
areas  of  the  body.  The  uniformly  pale  red,  flat  nevus,  not  elevated 
over  the  level  of  the  skin,  frequently  decreases  or  may  even  disappear 
spontaneously.  Even  those  forms  in  which  tumor  is  present  may 
disappear,  leaving  a  whitish  scar  but  they  usually  increase  in  size. 

Treatment. — In  many  cases  disfigurement  is  so  slight  that  no  treat- 
ment is  called  for;  in  other  cases  the  disfigurements  incident  to  a  cure 
might  be  worse  than  the  disease.  The  most  successful  treatment  of 
superficial  angiomata  without  tumor  formation,  consists  in  the  applica- 
tion of  carbon-dioxide  snow.  Ignipuncture,  electrolysis  and  the 
application  of  fuming  nitric  acid  are  all  means  of  treatment  inferior  to 
freezing. 

When  tumor  is  present  the  treatment,  when  required,  is  usually 
operative. 

Angioma  cavemosum  is  a  congenital  lesion  consisting  of  tissue 
similar  to  the  corpus  cavemosum  penis.  The  tumors  are  compress- 
ible but  rarely  pulsating,  often  grow  rapidly  and  may  communicate 
directly  with  the  intracranial  vessels.  Cavernous  angiomata  are 
generally  suitable  for  excision  except  when  they  are  suspected  of  com- 
municating with  intracranial  vessels  when  they  may  better  be  sub- 
jected to  ignipuncture. 

Angioma -racemosum ;  plexiform  angioma;  cirsoid  aneurism  is  a 
tumor  consisting  of  a  tangle  of  dilated  arteries.  It  is  sometimes  con- 
genital, sometimes  traumatic  in  origin.  It  may  grow  rapidly,  then 
remain  stationary  and  later  grow  again.  In  severe  cases  there  is  great 
danger  of  hemorrhage  being  induced  by  ulceration  or  trauma.  Cirsoid 
aneurisms  vary  much  in  size.     (Fig.  5  shows  an  extreme  example.) 

TreatiAent  of  Angiomata. — The  treatment  of  superficial  nevi  by 
freezing  has  been  already  described. 

Ignipimcture. — Heat  the  point  of  a  fine  brad  awl  or  similar  tool 
until  it  is  red  hot,  permit  it  to  cool  to  a  black  color  and  then  make  it 
penetrate  the  angioma.  After  a  few  seconds  remove  the  instrument, 
heat  it  again  and  introduce  it  at  another  spot.  Application  of  fuming 
nitric  acid  may  be  effected  by  a  method  exactly  the  same  as  ignipunc- 
ture except  that  instead  of  heating  the  brad  awl  (a  sharp  wooden 
toothpick  will  serve)  it  should  be  dipped  in  nitric  acid.  McBride 
notes  that  the  nitric-acid  treatment  is  often  followed  by  keloids. 

The  following  methods  of  treating  the  more  serious  forms  of  an- 
gioma, e.g.,  cirsoid  aneurism,  have  been  tried: 

I.  Pressure  applied  to  the  afferent  vessels,  no  value. 


1 6  REGIONAL   SURGERY 

2.  Ligation  of  the  afferent  vessels,  generally  valueless, 

3.  Ligation  of  both  common  carotid  arteries,  rarely  useful  and 
always  dangerous. 

4.  Injections  of  alcohol  or  of  sesquichloride  of  iron  have  given  some 
good  results  but  the  dangers  are  evident.  Injections  of  boiling  water 
are  of  equal  value  and  present  less  danger. 

5.  Excision,  where  possible,  is  good. 

Methods  of  Excision. — When  simple  nevi  of  the  scalp  require 
removal  by  operation,  the  incision  must  be  made  sufi&ciently  far  from 
the  disease  so  that  hemostasis  may  be  easily  effected;  the  wound,  if 
extensive,  may  tax  the  resources  of  plastic  surgery.  Rapidly  growing 
angiomata,  those  which  penetrate  the  subcutaneous  tissues  or  are  large 
and  tumor-like  and  those  which  bleed  or  threaten 
severe  hemorrhage,  all  call  for  operation. 

Angiomata    over    the  fontanelles  often  com- 
municate with  the    longitudinal  sinus;  hence  in 
jQ  ff  '\  these,  radical  operation  should,  if  possible,  give 

(^1,  y®       way  to  less  vigorous  measures  such  as  ignipunc- 

\  /J  ture.     The  same  is  true  in  the  case  of  cavernous 

'^r^^^  angiomata,  which  evidently  penetrate  the  skull. 

Methods  of  Operating.     {A)  Strangulation. — 

r  iG.    I .     ouDcut^ncous  ^  T  •  -I  11         (- 

ligation  angioma.  Pass  a  stout  pin  or  needle  under  the  middle  of 

the  nevus  from  side  to  side.  Pass  a  stout  thread 
around  the  base  of  the  nevus  under  the  pin  (which  keeps  the 
thread  from  slipping).  Tie  the  thread  very  tightly.  Instead  of  one, 
two  pins  may  be  introduced  at  right  angles  to  each  other.  In  time  the 
strangulated  tissues  die,  slough  off  and  leave  an  ulcer.  In  the  twentieth 
century  this  treatment  savors  of  barbarism. 

{B)  Subcutaneous  Ligation. — Many  methods  of  subcutaneous  liga- 
tion have  been  used;  most  of  them  are  exceedingly  simple. 

I.  At  the  points  A,  B,  C,  D  (Fig.  i)  puncture  the  scalp  with  a  knife. 
These  points  must  be  well  away  from  the  disease.  With  a  needle 
introduce  a  stout  chromicized  catgut  or  a  silk  suture  through  A  and 
bring  it  out  at  B,  reintroduce  it  at  B  and  bring  it  out  at  C;  in  the  same 
manner  carry  the  suture  from  C  to  D  and  from  D  to  A.  Both  ends  of 
the  suture  now  emerge  at  A.  Tie  the  suture  tightly  and  let  its  knot 
retract  under  the  skin  through  the  puncture  at  A.     Apply  dressings. 

II.  Krogius  ("Centralblatt  fiir  Chir.,"  Sept.  30,  1905)  found  that 
compression  and  ligation  even,  of  the  afferent  vessels  was  inefficient 
in  cases  of  large  racemse  (cirsoid)  angiomata  of  the  scalp;  that  igni- 


DISEASES    OF   THE    SCALP 


17 


CJU^v^ 


^/YW^A-^A^ 


Fig.  2. — Krogius  operation  angioma. 


puncture,  injections  and  excisions  were  dangerous,  he  therefore  operated 
as  follows: 

Arm  a  full  curved  needle  with  catgut.  Pass  the  needle  from  A  to  B 
(Fig.  2),  hugging  the  bone.  Remove  the  full  curved  and  substitute 
a  less  curved  needle.  With  this  pass  the  suture  from  B  to  A  immedi- 
ately under  the  skin  (Fig.  3).  Both  ends  of  the  suture  now  emerge  at 
A.     Tie  the  suture  tightly. 

Repeat  the  process  all 
round  the  nevus  until  prac- 
tically every  vessel  entering 
or  leaving  the  tumor  is  con- 
trolled. Each  suture  or 
ligature  should  to  some  ex- 
tent overlap  into  the  territory 
controlled  by  the  next  one. 

(C)  Bryant's  Operation. — Suitable  in  cases  of  cirsoid  growth.  Make 
an  incision  outside  and  nearly  round  the  growth,  down  to  the  perios- 
teum. Leave  undisturbed  that  portion  of  growth  containing  the 
largest  vessels.  Raise  the  flap  and  attend  to  hemostasis.  Apply 
dressings    under,    as    well    as    over,    the    flap.     When  the  wound  is 

covered  with  granulations, 
replace  and  suture  the  flap. 
If  after  elevation  of  the  flap 
for  a  few  days  pulsations  con- 
tinue in  the  flap  (the  tumor  is 
in  the  flap) ,  ligate  at  a  distance 
the  main  vessel  entering  it. 
This  method  has  given  J.  D. 
Bryant  much  satisfaction. 
In  a  case  of  angioma  of  the  lower  frontal  region  the  author  operated 
as  follows: 

1.  Shave  the  anterior  portion  of  the  scalp.  Make  a  transverse  inci- 
sion over  the  head  practically  from  ear  to  ear  but  inside  the  line  of  the  hair. 

2.  Reflect  the  skin  flap  thus  formed  downward  and  forward  until 
the  angioma  is  almost  reached  (Fig.  4).  At  this  point,  if  necessary, 
cut  through  the  deeper  structures  until  a  layer  of  tissue  is  found  beneath 
the  angioma  and  continue  the  reflection  of  the  flap  downward  in  this 
plane  until  the  lower  limits  of  the  angioma  are  passed.  Working  from 
the  underside  of  the  flap,  pass  sutures  or  ligatures  around  the  main 
vessels  entering  the  angioma  from  the  base  of  the  flap. 


Fig.  3. 


-Krogius'  operation  angioma. 


i8 


REGIONAL   SURGERY 


3.  Treat  the  flap  as  in  Bryant's  operation  and  a  few  days  later 
excise  the  tumor.  Replace  the  flap  and  close  the  wound  with  sutures. 
The  object  of  this  method  is  of  course  to  avoid  making  any  visible  scar. 

Clairmont  reports  from  v.  Eiselsberg's 
clinic  ("Archiv.  fiir  klin.  Chir.,"  Ixxxv, 
549)  an  operation  which  combined  the 
principles  of  Bryant's  operation  and  ex- 
cision. Following  Krause,  the  operation 
was  completed  in  two  sittings.  Figs.  5 
and  6  show  the  extent  of  the  disease. 
A  skiagram  showed  that  the  middle 
meningeal  arteries  were  much  enlarged. 
The  occipital  limits  of  the  tumor  were 
clearly  defined;  elsewhere  it  was  not  well 
delimited.  The  use  of  temporary  hemo- 
stasis  by  an  elastic  band  was  impossible. 
Preliminary  ligation  would  have  called  for  the  tying  of  both 
occipital   arteries,    the   frontal   artery    (the  size  of  the  little  finger), 


Fig.  4. 


Fig.  5. — {Clairmont.)  Fig.  6. — {Clairmont.) 

and  both  external  carotids  near  their  origin,  which  might  cause 
danger  of  embolism.  Communicating  vessels  between  the  scalp  and 
the  inside  of  the  skull  were  so  numerous  as  to  make  the  gain  from 
preliminary  ligations  very  doubtful.  The  operation  performed  may 
be  taken  as  a  guide  for  the  treatment  of  extremely  extensive  cirsoid 
aneurism  of  the  scalp. 

Place  the  patient  almost  in  a  sitting  posture.     Anaesthetize. 


DISEASES    OF   THE    SCALP  1 9 

Step  I. — Make  an  incision  through  the  skin  and  epicranial  aponeu- 
rosis skirting  the  growth  anteriorly  and  laterally.  Make  the  cut  Inch 
by  inch,  using  compression  on  each  side  of  the  cut  against  the  bone  until 
the  vessels  are  secured  by  forceps  and  ligatures.  Isolate  and  doubly 
ligate  the  main  vessels  before  dividing  them.  The  incision  outlines  a 
horseshoe-shaped  flap  having  its  base  at  the  occiput. 

Step  2. — Reflect  the  flap  from  the  cranium.  This  step  requires  the 
use  of  many  hemostats  and  ligatures  because  of  the  free  anastomosis 
with  the  deep  vessels. 

Step  3. — As  in  Bryant's  operation,  place  gauze  between  the  flap  and 
the  bone.  Replace  the  flap  over  the  gauze.  Apply  dressings  and 
bandage. 

Step  4. — After  three  or  four  days  remove  the  dressings  and  excise 
the  tumor  from  the  under-surface  of  the  flap.  Thrombosis  of  the 
vessels  in  the  tumor,  and  loosening  of  the  surrounding  connective  tisfeie 
due  to  oedema,  make  the  incision  of  the  growth  easier  than  it  would  have 
been  at  the  first  sitting. 

Step  5. — Replace  flap.     Suture.     Dress  the  wound. 

{D)  Excision. — It  is  very  easy  to  excise  small  nevi  and  to  close  the 
wound  with  sutures.  When  large  nevi  are  being  excised,  hemorrhage 
during  the  excision  may  be  avoided  by  tying  an  elastic  constrictor 
tightly  around  the  head  as  in  trephining  or  by  having  a  rubber-covered 
ring  (ring  pessary)  pressed  firmly  against  the  scalp  surrounding  the 
nevus.  The  operation  consists  in  excising  the  disease  by  cutting 
through  healthy  tissue,  in  securing  hemostasis  and  in  closing  the  wound 
either  directly  or  by  some  plastic  procedure. 

Aneurism. — The  scalp  may  be  the  site  of  any  variety  of  aneurism; 
usually  aneurism  of  the  scalp  is  traumatic  in  origin  and  is  least  unusual 
in  the  temporal  region. 

The  diagnosis  presents  no  difficulty.  Excision  is  usually  the  simplest 
and  most  satisfactory  treatment. 

Cirsoid  aneurisms  have  been  already  described. 

Sarcomata  of  the  scalp  are  often  secondary  to  neoplasms  of  the  skull 
but  the  tumors  may  arise  primarily  from  the  skin  and  the  fascia.  As  a 
result  of  irritation  or  from  unknown  cause,  pigmented  moles  may  be- 
come sarcomatous  forming  melanotic  and  most  malignant  tumors. 
The  sarcomata  of  the  fascia  form  lobulatcd  tumors  which  give  rise  to  vis- 
ceral metastases  though  in  a  less  degree  than  do  those  arising  from  moles. 

The  treatment  of  sarcomata  is  excision  but  generally  this  is  impos- 
sible as  the  disease  has  progressed  too  far  before  being  observed. 


20  REGIONAL   SURGERY 

Endotheliomata. — Hertzler  writes,  "These  tumors  occur  as  slow- 
growing,  papillary,  nodular,  or  ulcerated  masses.  When  small  they  may 
be  slightly  constricted  at  the  base  and  covered  with  epidermis  somewhat 
thinner  than  normal.  As  they  increase  in  size  they  tend  to  become 
nodular,  and  when  they  have  attained  the  size  of  a  split  walnut  they 
usually  ulcerate.  They  tend  to  heal,  only  to  break  down  again.  As 
the  tumor  increases  in  size  the  ulcerative  process  becomes  more  general 
until  the  entire  surface  is  affected.  The  growth  acquires  an  irregular 
granular  base  and  an  elevated,  undulating,  slightly  constricted  border. 
The  color  is  redder  than  the  surrounding  skin  and  is  mottled  with  dark 
blue  patches.  The  normal  skin  forms  a  wall  about  the  base  of  the 
tumor  and  terminates  at  the  edge  of  the  ulcer  in  a  thin,  sharply  defined 
margin  of  epidermis  resembling  very  much  the  division  of  normal  skin 
from  the  vascular  area  in  a  spina  bifida. 

;  "The  tumors  are  slow  of  growth,  and  usually  years  elapse  before  the 
ulcerative  stage  is  reached.  Secondary  nodules  occasionallv  form  in 
the  region  of  the  primary  tumor,  but  there  is  little  tendency  to  the 
formation  of  metastases.  However,  endotheliomas  have  been  known 
to  undergo  sudden  exacerbations  in  growth,  accompanied  by  rapid 
invasion  of  the  surrounding  tissue  and  the  formation  of  metastases. 
Tumors  identical  with  these  in  external  form  and  clinical  course  are 
sometimes  formed  of  cystic  epithelial  spaces.  Others,  again,  approach 
a  sarcomatous  structure. 

^^  Diagnosis. — Their  slow  growth  and  their  ulcerated,  thinned  epi- 
dermal covering  are  usually  sufficient  to  distinguish  them.  The 
ulceration  lacks  the  dirty  incrustation  of  epithelioma,  and  the  firm 
constricted  base  differs  markedly  from  carcinoma,  which  is  more  fun- 
goid, dense,  and  fades  gradually  into  the  surrounding  tissue.  Tuber- 
culous processes  are  less  elevated  and  the  outlines  are  less  regular. 
Syphilis  and  sarcoma  are  more  rapid  processes.  On  cross-section  the 
structure  resembles  carcinoma  very  closely,  and  careful  microscopic 
study  is  sometimes  required  to  differentiate  them.  Their  clinical 
features  furnish  a  safer  guide  to  diagnosis  than  does  the  gross  inspection 
of  the  cut  surface.  This  latter  point  should  be  remembered,  for  no 
doubt  many  of  these  tumors  are  classed  as  carcinoma. 

"  Treatment. — Simple  excision  results  in  a  cure.  If  sufficient  tissue 
is  not  removed  local  recurrence  may  take  place,  but  persistence  in  the 
removal  of  the  local  recurrences  will  result  in  a  permanent  cure.  When 
the  period  of  rapid  growth  has  been  reached  the  prognosis  is  much  less 
favorable,  and  even  wide  excision  is  usually  followed  by  rapid  recurrence 
and  metastases." 


DISEASES    OF   THE    SCALP  21 

Epitheliomata  are  not  common  on  the  scalp.     They  may  arise  from 

warts  or  ulcerated  sebaceous  cysts  when  they  tend  to  give  rise  to 
fungus-like  masses  or  they  may  assume  a  flat  ulcerating  type  of  slow 
growth  and  may  exist  for  a  long  time  without  metastasis.  Epithe- 
liomata of  the  scalp  tend  to  grow  into  the  bone  and  even  through  it. 

Treatment  consists  in  thorough  excision,  when  possible  accompanied 
by  the  excision  of  the  lymph  nodes  of  the  territory  into  which  the 
affected  portion  of  the  scalp  drains.  If  excision  i^  impossible,  exposure 
to  X-rays  may  be  tried. 


SECTION  III 
TRAUMATA  OF  THE  SKULL  AND  CONTENTS 

By 

JAMES  HOGARTH  PRINGLE,  M.  B.,  C.  M.  (Ed),  F.  R.  C.  S.  (Eng.) 

Glasgow 

ANATOMY  AND  MECHANICS  OF  INJURIES  TO  THE  SKULL  AND 

ITS  CONTENTS 

The  injuries  resulting  from  the  effects  of  violence  applied  to  the 
skull  vary  considerably  in  different  cases,  and  to  some  extent  these 
variations  are  brought  about  by  the  anatomical  peculiarities  of  the 
skull  itself.  First,  its  shape,  spheroidal,  gives  the  skull  a  high  degree 
of  elasticity  even  in  the  completely  ossified  box  of  the  adult;  while  in 
the  young  the  absence  of  synostosis  adds  further  to  the  elasticity. 
The  vault  of  the  skull  is  probably  stronger  than  the  base,  in  part 
because  of  its  dome-like  shape,  but  also  because  in  the  greater  part 
of  its  extent  its  structure,  two  tables,  inner  and  outer,  of  compact  bone 
separated  by  a  layer  of  cancellous  tissue,  the  diploe,  affords  a  greater 
degree  of  elasticity  than  that  of  the  base  where  cancellous  tissue  is 
practically  absent  save  in  the  dorsum  ephippii.  The  bones  entering 
into  the  formation  of  the  base  of  the  skull  are,  further,  perforated  by 
numerous  foramina  of  varying  sizes;  and  several  are  hollowed  out  to 
form  special  cavities  such  as  the  tympanum.  Eustachian  tube,  carotid 
canal  and  sphenoidal  cells. 

Elasticity  plays  a  much  greater  part  in  the  production  of  fractures 
of  the  skull  than  it  does  in  the  case  of  the  other  bones  of  the  body. 
We  are  specially  indebted  to  Messerer  for  his  careful  observations 
regarding  the  elasticity  of  the  skull.  He  found  that  skulls  were  more 
resistant  to  pressure  in  the  sagittal  than  in  the  transverse  axis  and 
were  more  resistant  in  the  transverse  than  in  the  vertical  axis.  The 
longer  a  skull  is  in  its  sagittal  axis  the  stronger  it  is  in  that  direction 
and  the  less  resistant  in  its  transverse  axis. 

A  fracture  of  the  skull  results  whenever,  as  the  consequence  of  the 
application  of  violence,  the  elasticity  of  the  bone  is  overcome;  and 

23 


24  REGIONAL    SURGERY 

the  tj'pe  of  fracture  which  results  depends  upon  the  elasticity  of  the 
individual  skull  involved  and  the  directness  or  diffuseness  with  which 
the  violence  acts.  The  violence  may  be  applied  in  one  of  several 
ways;  thus  it  may  be  in  the  form  of  (i)  diffused  violence  which  is  either 
sudden  or  gradual  in  its  action;  (2)  localized  violence  which  is  suddenly 
applied;  (3)  it  may  be  the  result  of  the  action  of  some  sharp  weapon; 
or  (4)  it  may  be  by  means  of  firearms. 

Fractures  produced  by  diffused  violence  constitute  the  greater 
number  of  cases  met  with  in  civil  practice. 

The  manner  in  which  these  fractures  are  brought  about  has  been 
correctly  explained  by  the  work  of  Messerer,  Hermann  and  Wahl. 

Occasionally  in  actual  practice  a  person's  skull  is  caught  between 
two  wagons  or  between  a  moving  wagon  and  a  wall;  the  two  points  at 
which  the  skull  is  compressed  may  be  looked  on  as  two  poles  and 
between  these  there  may  be  considered  to  be  a  series  of  meridian  lines 
passing  at  right  angles  to  the  "equator"  of  the  skull  and  the  series  of 
equatorial  circles  parallel  to  it.  Compression  at  the  two  poles  will 
shorten  the  diameter  of  the  skull  between  them  and  at  the  same  time 
expand  the  circle  of  the  equator  and  the  circles  parallel  to  it;  i.e.,  it 
will  cause  a  stretching  of  the  osseous  tissue  to  take  place  along  these 
circles  which  will  continue  until  the  cohesion  of  the  osseous  tissue  is 
overcome  and  then  a  tear  will  result  at  right  angles,  more  or  less,  to  the 
equatorial  circles  and  parallel,  more  or  less,  with  one,  the  weakest,  of  the 
longitudinal  meridians.  It  is  a  "bursting"  action,  and  (provided  the 
violence  ceases  at  the  moment  of  its  production)  always  results  in  a 
fissure  of  the  skull  being  produced;  the  skull  bursts  outward,  and  the 
fracture  gapes  at  the  moment  of  its  production,  and  as  a  result  of  this, 
in  the  case  of  open  fractures,  hairs  are  quite  frequently  caught  between 
the  lips  of  the  fracture;  or,  in  the  case  of  basal  fractures  of  the  anterior 
fossa,  the  fat  of  the  orbital  cavity  gets  in  between  the  two  margins 
of  the  fracture. 

When  violence  is  applied  bilaterally  the  skull  fractures  through  the 
base  in  the  first  instance,  and  fissures  may  be  limited  to  that  region  or 
may  extend  so  as  to  involve  the  sides  or  even  the  vault. 

Whenever  they  are  produced,  bursting  fractures  lie  parallel  to  the 
axis  of  the  force:  if  compression  takes  place  in  the  antero-posterior 
direction,  a  fracture  running  in  the  antero-posterior  direction  is  pro- 
duced; if  the  compression  be  transverse  or  oblique,  a  fracture  running  in 
the  corresponding  direction  results. 

In  practice  fractures  occur  more  usually  from  the  effects  of  violence 


TRAUMATA    OF    THE    SKULL   AND   CONTENTS  25 

applied  to  one  side  of  the  skull,  and  when  the  violence  is  diffuse, 
bursting  fractures  are  again  produced,  though  they  are  often  not  so 
extensive  as  when  bilateral  compression  has  taken  place.  The  fracture 
too,  in  this  case,  begins  usually  at  that  area  of  the  bone  which  bears  the 
brunt  of  the  injury  and  from  that  point  may  spread  to  the  base,  and 
a  fracture  completely  dividing  the  skull  into  two  lateral  portions  or 
into  an  anterior  and  a  posterior  portion  may  result.  But  fractures  so 
caused  do  not  invariably  run  into  the  base;  they  sometimes  run  an 
antero-posterior  course  along  the  side  of  the  skull,  and,  in  what  are 
certainly  rare  instances,  the  fracture  may  run  completely  around  the 
skull,  encircling  it  and  separating  the  calvarium  from  the  remainder  of 
the  bone,  the  "pot-lid"  fracture. 

After  unilateral  compression  it  is  not  uncommon  to  find  that  several 
fissures  begin  at  the  point  assaulted,  and  radiate  off  from  this  spot  in  the 
lines  of  the  longitudinal  meridians  of  this  **pole." 

A  skull  may  be,  and  often  is,  assaulted  in  various  axes,  one  after 
another,  and  in  each  of  these  a  fracture  may  result,  each  in  the  axis  of  the 
pressure  that  caused  it,  though  they  are  not  necessarily  parallel  to  one 
another;  while  on  the  other  hand  two,  or  more,  quite  separate  fissures 
may  be  met  with,  caused  by  a  compressing  agent  having  a  sufficiently 
large  surface  acting  on  one  side  of  the  skull,  in  which  case  the  fissures 
are  practically  parallel  to  one  another. 

Fractures  of  the  base  occur  with  more  certainty  the  nearer  the  area  of 
the  skull  assaulted  is  to  the  base.  Aran's  law,  that  a  fracture  arrived 
at  the  base  by  the  shortest  route,  that  is,  ''followed  the  course  of  the 
shortest  radius,"  applies  to  a  certain  number  of  cases;  but  it  is  quite 
certain  that  a  large  number  of  fractures  begin  in  the  base  of  the  skull  at 
a  distance  from  the  site  of  the  impact  of  the  violence. 

If  the  violence  which  causes  a  bursting  fracture  continues  to  act 
after  the  latter  has  developed,  the  first  effect  will  be  to  cause  a  wider 
gaping  of  the  fracture's  margins,  but  the  elasticity  of  the  skull  as  a 
whole  having  been  overcome,  the  effect  of  the  violence  is  now  more 
localized  and  a  second  fracture  is  caused  which  runs  more  or  less  at 
right  angles  to  the  axis  of  pressure,  i.e.,  in  an  equatorial  circle  and  not 
in  one  of  the  longitudinal  meridians.  This  fracture  is  brought  about 
by  "bending"^  action;  and  the  line  of  fracture  may  approximate  to  or 
be  an  actual  circle.  It  often  happens  that  one  bending  fracture  is 
produced  after  another,  the  result  being  a  series  of  concentric  ring 
fractures.  One  variety  of  fracture  by  bending  action  is  very  character- 
istic and  is  seen  in  the  neighborhood  of  the  foramen  magnum;  it  is  often 


26  REGIONAL   SURGERY 

spoken  of  as  the  "ring  fracture."  It  is  the  result  of  a  fall  from  a 
height,  or  a  dive  into  shallow  water,  etc.,  when  the  head  of  a  person 
impinges  on  the  ground  and,  with  the  momentum  of  the  trunk  following 
on,  the  atlas  is  driven  violently  against  the  occipital  condyles  and 
fractures  the  occipital  bone.  The  line  of  this  fracture  commences  on 
either  side  of  the  foramen  magnum  and  often  runs  on  into  the  jugular 
foramen  where  it  may  end,  but  the  fracture  may  continue  on  into  the 
middle  fossa,  and  frequently  the  two  fissures  unite  in  the  sella  turcica. 

This  fracture  may  not  be  a  complete  "ring;"  it  is  sometimes  limited 
to  one  side  of  the  skull  only,  and  this  in  all  probability  depends  upon 
the  position  of  the  head  in  relation  to  the  vertebrae  at  the  moment  of 
impact,  i.e.,  whether  it  is  reflexed  forward,  backward,  or  laterally  at 
the  time. 

Bending  fractures  are,  however,  caused  independently  of  bursting 
fractures  and  are  always  the  result  of  localized  violence;  the  smaller 
the  surface  of  the  wounding  object  the  more  absolutely  localized  is  the 
resulting  fracture.  The  type  of  this  fracture  is  what  is  often  spoken  of 
as  a  "Pond"  or  "Gutter"  fracture.  It  is  quite  frequent  in  these 
fractures  to  find  that  the  internal  table  is  more  extensively  broken 
than  the  external;  and  further,  the  two  tables  of  the  skull  in  the  frac- 
tured area  are  frequently  separated  from  one  another  horizontally  along 
the  diploe.  Fragments  of  the  internal  table  in  this  type  of  fracture 
occasionally  get  displaced  beneath  the  surrounding  intact  bone  and 
are  often  responsible  for  lacerations  of  the  dura  mater  and  injuries  to 
the  brain  or  its  vessels. 

When  violence  acts  sharply  and  suddenly  upon  the  unsupported, 
freely  swinging  head  an  area  of  bone  is  depressed  toward  the  interior 
of  the  skull  quite  frequently  without  the  remainder  of  the  skull,  or  its 
contents,  suffering  in  any  way  whatever;  the  individual  may  not  even 
fall  and,  when  he  does,  he  is  often  not  unconscious.  On  the  other 
hand,  when  the  violence  is  more  diffused,  if  the  wounding  object  have  a 
broad  surface,  a  patient  is  generally  knocked  over,  and  he  may  or  may 
not  be  rendered  unconscious.  If  a  fracture  is  produced  in  the  latter 
case  it  is  generally  of  the  bursting  type;  whereas  in  the  former  case  it  is 
a  bending  fracture. 

If  the  violence  has  its  effects  more  directly  at  the  base  of  the  skull, 
instead  of  the  vault  (as  in  the  knockout  blow  on  the  mandible  in  a 
prize  fight),  the  patient  falls  unconscious  at  once. 

The  effect  upon  a  skull  is  the  more  localized  the  smaller  the  surface 
of  the  wounding  object.     Messerer  showed  that  with  a  bolt  2  cm.  in 


TRAUMATA  OF  THE  SKULL  AND  CONTENTS  27 

diameter  he  could  produce  a  clean-cut  opening  in  the  skull  without 
radiating  fissures.  With  a  bolt  4  cm.  in  diameter  he  produced  holes 
with  fissures  of  the  surrounding  bone,  with  a  broad  plate  he  only 
caused  fissures;  and  clinical  experience  bears  this  out. 

Occasionally  a  fracture  involving  the  internal  table  alone  is  caused; 
it  is  the  result  of  a  tearing  of  the  bone  at  the  summit  of  the  depression 
caused  by  the  impact,  and  always  the  margins  of  the  fracture  are 
depressed  toward  the  brain.  Such  fractures  are  of  importance  for  they 
cause  few  signs  at  the  time,  but  may  be  a  source  of  irritation  of  the 
brain  later  on,  leading  to  epilepsy  or  mental  disturbance. 

Fractures  of  the  Skull  in  Infants. — Although  fractures  do  un- 
doubtedly occur  during  intrauterine  life,  due  to  violence  applied  to  the 
foetal  skull  through  the  maternal  structures,  they  are  distinctly  rare. 

During  labor,  however,  it  is  not  uncommon  to  find  that  fractures 
either  complete  or  incomplete  are  brought  about.  The  incomplete 
fractures  are  either  indentations  or  partial  tears  of  bone,  the  frontal  or 
parietal  bones  being  most  often  aft'ected;  and  they  result  from  pressure 
of  the  forceps  or  of  the  sacral  promontory.  Complete  fissures,  usually 
involving  one  of  the  parietal  bones,  also  occur  during  labor,  or  oc- 
casionally a  diastasis  of  one  of  the  sutures  is  brought  about.  After 
birth,  partial  or  greenstick  fractures  are  met  with  now  and  then  in 
young  children,  but  only,  as  a  rule,  before  the  time  at  which  the  diploe 
develops  and  separates  the  two  layers  of  the  bones. 

Fracture  by  Contre-coup.— It  occasionally  happens  that  two  or 
more  isolated  and  distinctly  separate  fractures  are  found  in  a  skull  as 
the  result  of  the  same  assault.  In  such  a  case  the  second  fracture  may 
be  an  indirect  fracture,  for  if  the  violence  has  been  diffuse,  a  portion 
of  the  skull  (especially  at  the  base)  which  is  thin  and  brittle,  like  the 
roof  of  the  orbit,  may  break  in  consequence  of  the  distorting  strains  to 
which  it  is  subjected. 

However,  in  some  cases  true  isolated  fractures  are  met  with  which 
are  due  to  violence  directly  applied  at  two  opposed  points  of  the  skull; 
thus,  a  person  receives  a  blow  over  the  front  of  the  skull  which  fractures 
the  bone  at  that  region  and  fells  him;  in  falling  the  occiput  may  come 
into  contact  with  hard  ground,  a  flagstone,  etc.,  and  a  second  local 
fracture  may  be  produced  in  that  region  from  direct  violence. 

Fractures  Caused  by  Sharp  Weapons. — These  injuries  are  in  reahty 
fractures  produced  by  bending  action  and  caused  by  objects  which  are 
pointed  or  have  only  a  small  surface,  e.g.,  daggers,  knives,  pencils,  pens, 
pitch-forks,  umbrella  ribs,  etc.     They  are  met  with  both  at  the  vault 


28  REGIONAL   SURGERY 

and  at  the  base.  When  a  very  fine  instrument,  such  as  a  bodkin,  the  rib 
of  an  umbrella,  etc.,  causes  the  injury  it  is  rather  of  the  nature  of  a 
punctured  wound  of  bone  than  a  fracture;  and  while  weapons  having  a 
larger  superficial  area  may  still  produce  "punctures"  of  the  bone,  the 
margins  of  the  opening  generally  show  fine  radiating  fissures  running 
off  in  various  directions,  though  often  these  fissures  are  so  small  that 
they  cannot  be  made  out  until  the  skull  is  macerated.  Injuries  of 
this  class  are  of  the  greatest  importance,  for  the  instrument  causing 
them  is  usually  carried  into  the  membranes  or  the  substance  of  the 
brain  itself,  thereby  directly  implanting  infection  in  the  interior  of  the 
cranial  cavity.  The  instrument  is  occasionally  broken  and  a  portion 
of  it,  e.g.,  the  blade  of  a  dagger,  left  behind  in  the  wound.  In  the  case 
of  fractures  of  this  type  involving  the  base  of  the  skull,  and  caused  by 
pencils,  penholders,  walking  sticks,  etc.,  being  forced  through  the  nasal 
or  orbital  cavities,  the  eye,  the  optic  nerve,  or  some  of  the  great  vessels 
at  the  base  of  the  skull,  the  cavernous  sinus  or  the  internal  carotid 
artery,  etc.,  may  be  injured.  The  diagnosis  of  a  fracture  of  this  nature 
from  mere  clinical  examination  of  the  part  is  not  always  easy,  as  the 
weapon,  or  the  external  part  of  it,  is  frequently  removed  before  the 
patient  is  brought  for  medical  assistance. 

Fractures  are  sometimes  brought  about  through  the  agency  of 
weapons  having  a  broad  and  wedge-shaped  edge,  such  as  a  sword  or 
hatchet,  when  either  complete  or  incomplete  wounds  of  the  skull  are 
caused.  If  a  direct  blow  is  given  to  the  skull  by  such  a  weapon  and 
penetration  occurs,  it  generally  happens  that  extensive  splintering  of 
the  internal  table  is  brought  about  along  with  injury  to  the  brain  or  its 
membranes.  But  if  the  blow  be  a  tangential  or  glancing  one  the 
effects  may  be  various:  (i)  a  slice  of  the  vault  of  the  skull  with  the 
adherent  scalp  may  be  cut  clear  away  from  its  surroundings,  (2)  a  slice 
of  bone  may  be  elevated  above  the  level  of  the  surrounding  bone  though 
not  necessarily  separated  from  it,  (3)  the  bone  slice  may  be  turned  up 
free  from  its  bone  attachments  but  with  a  scalp  pedicle  holding  it  to 
the  rernainder  of  the  scalp,  very  much  like  the  osteoplastic  skull-flap  of 
the  surgeon.  In  such  cases  fine  fissures  can  generally  be  shown  to  exist 
in  the  margin  of  the  surrounding  skull  radiating,  meridian-wise,  from 
the  area  which  has  been  assaulted.  The  brain  and  membranes  may  or 
may  not  be  injured  at  the  same  time;  the  dural  sinuses  are  said  to  be 
more  often  involved  than  the  arteries  in  this  type  of  fracture. 

The  Types  of  Fracture  of  the  Skull. — These  may,  in  the  first  place, 
be  described  as  incomplete  and  complete  fractures. 


TRAUMATA  OF  THE  SKULL  AND  CONTENTS  29 

An  incomplete  fracture  may  involve  the  external  table  only  or  the 
internal  table.  Those  of  the  external  table  are  met  with  at  the  frontal 
sinuses,  the  mastoid  cells,  or  sometimes  at  the  occipital  protuberance 
where  there  is  an  excess  of  the  diploe.  *  They  are  seen  as  fissures  or  as 
comminuted  fractures  with  or  without  depression  of  the  fragments,  or, 
in  rare  instances,  with  elevation.  Very  rarely  an  incomplete  fracture 
is  seen  involving  the  internal  table  alone,  nearly  always  the  result  of 
extremely  localized  violence  of  considerable  intensity. 

Complete  fractures  may  be  (i)  fissures,  which  occur  in  great 
variety.  They  may  be  single  or  branched  or  multiple;  they  are  at 
one  time  straight  lines,  at  another  they  run  a  curved  or  zigzag  course. 
They  may  cut  across  one  of  the  sutures  of  the  skull;  at  another  time 
follow  the  line  of  a  suture,  causing  a  diastasis;  or,  again,  after  producing 
diastasis  for  a  certain  distance,  a  fissure  may  diverge  from  the  suture 
and  run  off  at  an  angle  from  it.  The  direction  followed  is  determined, 
in  any  individual  case,  by  the  nature  and  direction  of  the  violence,  the 
thickness  of  the  skull,  the  presence  or  absence  of  foramina,  sutures, 
etc.,  and  the  "graining"  of  the  bones  at  the  area  involved. 

They  are  caused  by  either  a  bending  or  a  bursting  force. 

2.  Comminuted  fractures  are  often  extremely  localized,  in  which 
case  there  may  be  considerable  depression  of  the  bone,  the  internal 
table  being  always  more  extensively  fractured  than  the  external. 
This  type  of  fracture  is  the  result  of  a  bending  action. 

3.  Punctured  fractures  are  bending  fractures  produced  by  small, 
and  especially  by  pointed,  objects.  The  smaller  the  object  the  cleaner 
is  the  perforation  produced;  the  internal  table  is  always  fractured  more 
extensively  than  is  the  external,  and  in  some  instances  a  portion  of  the 
bone  is  driven  into  the  cavity  of  the  cranium — "fractures  with  loss  of 
substance"  or  "hole-fractures."  They  are  invariably  open  injuries, 
only  one  case  of  a  closed  punctured  fracture,  i.e.,  without  a  wound  of 
the  soft  parts  over  it,  being  known  to  the  writer  as  having  been  recorded. 

4.  Elevated  fractures  have  been  sufficiently  referred  to  in  discussing 
the  mechanism  of  the  production  of  fractures.  Any  of  the  above-noted 
types  of  fractures  may  be  "closed"  or  "open"  ("simple"  or  "com- 
pound"), a  distinction  of  the  greatest  importance,  as  sepsis,  with  the 
possible  involvement  of  the  intracranial  structures,  is  the  most  serious 
complication  that  can  occur  in  these  cases. 

Fractures  of  the  base  of  the  skull  are  as  a  rule  either  of  the  fissured 
or  punctured  type.  They  are  very  frequently  open  fractures,  the 
mucous  membrane  of  the  ethmoidal  cells  being  so  often  lacerated  in 


3©  REGIONAL   SURGERY 

fractures  of  the  anterior  fossa,  or  that  of  the  roof  of  the  nasopharynx 
in  the  case  of  a  middle  fossa  fracture.  The  latter  may  also  be  rendered 
an  "open"  fracture  if  the  tympanic  cavity  should  be  implicated  (i)  in 
consequence  of  its  communication  with  the  pharynx  or  (2)  by  a  rupture 
of  the  tympanic  membrane. 

THE  SIGNS  OF  FRACTURES  OF  THE  SKULL 

A.  Fractures  of  the  Vault.- — The  diagnosis  of  these  injuries  is  in 
some  cases  the  easiest  possible,  and  in  others  as  difficult  as  any. 

An  open  depressed  fracture  of  the  vault  is  obvious  at  once  in  most 
cases;  fissures  show  up  at  the  bottom  of  a  scalp  wound  as  red  lines  which 
persist  in  the  exposed  bone  in  spite  of  wiping,  as  the  blood  lies  between 
the  margins  of  the  crack.  Where  a  fracture  is  suspected  in  the  presence 
of  a  wound  of  the  scalp,  the  use  of  a  probe  is  not  only  dangerous  but  it  is 
uncertain;  the  only  instruments  to  employ  for  the  examination  are  the 
eyes  and  an  aseptic  finger.  If  a  wound  be  too  small  to  permit  inspec- 
tion of  the  bone,  and  if  the  latter  can  be  examined  only  by  digital 
palpation,  a  natural  groove  in  the  bone,  a  suture,  or  even  a  slit  in  the 
pericranium  may  be  mistaken  for  a  fracture.  In  such  a  case,  if  doubt 
still  remains,  the  wound  ought  to  be  enlarged  sufficiently  to  permit 
accurate  palpation  and  ocular  inspection. 

Where  no  wound  exists  a  fissure  can  at  times  be  palpated  through 
the  scalp;  this  depends  upon  the  degree  of  gaping  of  the  margins  and 
the  degree  of  swelling  of  the  scalp.  Depressions  of  the  skull  bones  are 
generally  readily  recognized;  the  movement  communicated  by  the 
examining  hand  to  a  loose  fragment  of  bone  can  at  times  be  made  out, 
and  in  rare  instances  bony  crepitus  can  be  felt  in  cases  where  com- 
minution exists. 

One  must  not  mistake  the  irregularities  of  sutures  or  the  presence  of 
Wormian  bones  for  fractures. 

Hematomata  of  the  scalp  often  cause  difficulty  in  one's  decision  as 
to  the  presence  of  a  fracture.  The  hematoma  itself  frequently  brings 
about  a  state  of  things  closely  resembling  a  depressed  fracture,  present- 
ing a  firm  zone  at  its  circumference  which  bounds  a  central  depression. 
Steady  pressure  over  the  firmer  peripheral  zone  of  the  hematoma, 
which  is  frequently  elevated  above  the  level  of  the  surrounding  scalp, 
permits  the  finger  to  sink  through  the  swelling  until  it  reaches  bone. 
The  resemblance  to  a  fracture  is  at  times  so  close  that  a  decision  can 
be  arrived  at  only  by  an  incision  through  the  tissues  to  the  bone  and 


TRAUMATA   OF    THE    SKULL   AND    CONTENTS  $1 

a  direct  examination  of  that  structure.  Examination  of  skulls  with 
hematomata  by  means  of  the  X-rays  has  shown  that  in  many  cases, 
especially  in  childhood,  a  fissure  exists  below  the  effused  blood. 

The  writer  has  found  great  help  in  the  systematic  percussion  of  the 
heads  of  patients  who  have  sustained  injury,  and  has  come  to  look 
upon  it  as  a  valuable  aid  in  the  diagnosis  of  fractures  of  the  vault.  The 
results  are  more  certain  when  the  head  has  been  shaved,  though  the 
change  in  the  note  is  quite  often  distinctly  recognizable  prior  to  the 
shaving.  If  the  patient  is  conscious  he  should  sit  up  and  keep  the 
mouth  closed;  if  sitting  up  be  impossible,  the  head  should  be  supported 
by  one  hand  beneath  the  occiput  while  a  finger  of  the  other  hand  is 
free  to  percuss  over  corresponding  areas  of  the  two  sides  of  the  skull. 
In  the  region  of  a  fracture  the  note  obtained  is  lowered  in  pitch  and 
frequently  has  a  cracked-pot  sound  which  is  always  most  pronounced 
in  cases  of  T-,  L-  or  V-shaped  fissures,  and  is  best  marked  when  the 
percussing  finger  strikes  the  angular  portion  of  bone  between  the  limbs 
of  the  "T"  "L"  or  "V."  The  note  obtained  is  blurred  in  cases  where 
there  is  hemorrhage  into  the  subaponeurotic  space,  or  where  there  is 
edema  of  the  scalp  tissues.  Further,  in  conscious  patients  with  a 
fissure  of  the  skull  vault,  percussion  in  the  immediate  neighborhood 
of  the  line  of  fracture  often  produces  pain,  always  along  the  same  line, 
and  during  many  days  after  the  infliction  of  the  injury. 

Another  sign  of  some  importance  is  the  escape  of  blood  from  the 
interior  of  the  skull  beneath  the  scalp  and  the  formation  of  a  diffuse 
hematoma;  this  is  seen  most  characteristically  in  cases  of  fissures  cross- 
ing the  middle  meningeal  artery  or  one  of  the  venous  sinuses  of  the  dura. 
The  hematoma  may  reach  considerable  dimensions  and  produce  great 
tension  of  the  overlying  parts;  in  rare  cases  it  may  pulsate. 

Open  fractures  of  the  vault  are  generally  evident  at  once.  Cerebro- 
spinal fluid  may  escape  in  some  instances,  and  in  other  and  more  severe 
cases  brain  matter  is  found  in  both  closed  and  open  fractures. 

B.  Fractures  of  the  Base  of  the  Skull. — In  these  case  the  diag- 
nosis is  aided  by  the  escape  of  (i)  blood,  (2)  cerebro-spinal  fluid, 
(3)  brain  tissue,  (4)  air  or  (5)  by  the  involvement  of  various  cranial 
nerves. 

I.  (a)  Bleeding  into  the  tissues  occurs  at  the  orbits  or  at  the  mastoid 
region.  At  the  orbit,  blood  appears  beneath  the  conjunctiva  at  either 
the  external  or  internal  can  thus  and  spreads  forward  over  the  eye;  it  is 
in  the  majority  of  cases  due  to  a  fracture  of  the  anterior  fossa  of  the 
skull.     The  eye-lids  show  marked  discoloration,  and  the  lower  lid  in 


32  REGIONAL   SURGERY 

particular  becomes  baggy  from  cedema.  In  some  cases  the  amount 
of  blood  extravasated  into  the  orbit  is  so  great  as  to  produce  exophthal- 
mos. Bruising  at  the  tip  of  one  mastoid  process  and  along  the  anterior 
margin  of  the  sternomastoid  muscle  occurring  three  or  four  days  after 
injury  to  the  head  is  usually  the  result  of  a  fracture  of  the  posterior 
fossa.  When  bruising  occurs  at  both  mastoid  processes  it  is  an  indica- 
tion of  a  complete  transverse  fracture  of  the  base  of  the  skull. 

(b)  The  escape  of  blood  from  the  cavities  in  proximity  to  the  brain, 
e.g.,  the  nose,  mouth,  or  ears,  takes  place  in  some  instances.  Hemor- 
rhage from  the  nasal  cavities  taken  in  conjunction  with  other  symptoms 
is  at  times  of  value  as  a  diagnostic  aid,  though  taken  alone  it  is  not  of 
much  help,  as  the  nose  is  so  liable  to  direct  injury.  In  fracture  of  the 
skull  nasal  hemorrhage  is  due  to  fracture  of  the  ethmoid  bone  and 
laceration  of  the  mucous  membrane  lining  the  ethmoidal  cells,  and 
perhaps  to  tearing  of  the  ethmoidal  arteries;  it  is  not  great  in  amount  as 
a  rule.  In  some  cases  it  may  be  most  profuse  and  is  then  due  to  tear- 
ing of  one  of  the  large  vessels  inside  the  skull,  e.g.,  the  superior  longi- 
tudinal on  the  cavernous  sinus. 

Bleeding  from  the  mouth  may  occur  in  fractures  of  all  three  fossae 
of  the  skull.  From  the  anterior  fossa  blood  runs  back  to  the  naso- 
pharynx. From  the  middle  fossa  it  may  escape  into  the  nasopharynx 
from  one  or  both  of  the  sphenoidal  cells;  from  the  posterior  fossa  with 
involvement  of  the  tympanum  the  blood  may  pass  down  by  the 
Eustachian  tube.  By  whichever  route  it  reaches  the  nasopharynx, 
the  blood  at  times  escapes  from  the  mouth  almost  at  once;  at  other 
times  it  is  swallowed  to  be  vomited  later  on.  As  a  rule  the  amount 
lost  by  this  route  is  small,  but  it  may  be  so  great  (as  where  a  carotid 
artery  is  torn  in  a  middle  fossa  fracture)  as  to  lead  rapidly  to  death  from 
hemorrhage. 

The  escape  of  blood  from  the  auditory  meatus  is  fairly  frequent  in 
head  injuries,  but  it  is  not  always  the  result  of  a  fracture  involving  the 
cranial  fossa,  though  of  course  it  frequently  is.  Bleeding  may  occur 
from  rupture  of  the  tympanic  membrane,  from  fractures  of  the  osseous 
meatus  with  or  without  fracture  of  the  mastoid  process,  or  from  partial 
separation  of  the  auricle  from  the  bone.  Bleeding,  the  result  of  frac- 
tures involving  either  the  middle  or  posterior  fossae,  occurs  from  the 
external  auditory  meatus  in  a  certain  number  of  cases;  it  is  generally 
not  profuse,  but  lasts  many  days,  is  venous  in  character  in  the  majority 
of  cases,  and  is  probably  due  to  injuries  of  the  superior  petrosal  sinus 
or  the  mastoid  cells.     When  it  is  arterial,  which  is  rare,  it  occurs  from 


TRAUMATA   OF    THE    SKULL   AND    CONTENTS  33 

branches  of  the  meningeal  artery.  Hemorrhage  into  the  tympanic 
cavity  is  now  and  then  seen  at  a  post-mortem  examination  where  none 
has  escaped  from  the  meatus  owing  to  the  membrana  tympani  re- 
maining intact;  in  such  cases  the  membrane  has  a  bluish  appearance 
during  life.  When  the  latter  is  ruptured  it  is  often  possible  to  see  the 
tear  through  a  speculum. 

Aural  bleeding  is  a  sign  of  some  importance  in  skull  fractures. 
Crandon  and  Wilson  found  that  in  cases  of  hemorrhage  from  one  ear 
there  was  a  mortality  of  39  per  cent.,  while  when  it  occurred  from  both 
ears  the  mortality  was  66  per  cent. 

II.  The  escape  of  cerebrospinal  fluid  from  the  nose  or  ear  is  met 
with,  but  not  often  on  the  whole.     From  the  nose  it  is  decidedly  rare. 

From  the  auditory  meatus  it  usually  begins  within  24  hours 
from  the  time  of  the  accident.  It  is  tinged  with  blood  at  first, 
though  often  it  comes  quite  clear;  and  it  is  often  discharged  quickly  and 
freely,  soaking  dressings  time  after  time,  and  may  continue  for  days; 
in  one  case  the  writer  saw  it  continue  for  12  days,  pints  of  it  being 
discharged  during  that  period.  Forced  expiratory  efforts  generally 
cause  a  rapid  flow  during  their  performance. 

III.  Brain  tissue  escapes  from  the  nose  or  ears  in  a  few  rare  cases,  and 
constitutes  the  most  certain  evidence  there  can  be  of  a  fracture  of  the 
base  with  rupture  of  the  membranes  of  the  brain.  It  is  rare  from  the 
ear,  and  still  more  so  from  the  nose;  its  occurrence  signifies  considerable 
disintegration  of  the  brain  with  dislocation  of  bone  fragments. 

IV.  Emphysema  of  the  subcutaneous  tissues  is  a  rare  sign  of  frac- 
ture; it  occurs  only  after  fractures  involving  either  the  frontal  sinuses 
on  the  mastoid  cells,  and  in  both  situations  after  a  patient  has  made 
forced  expiratory  efforts.  The  emphysema,  when  it  occurs,  is  strictly 
limited  to  the  immediate  neighborhood  of  the  injured  bone. 

V.  Injuries  to  the  cranial  nerves  occur  and  aft'ord  valuable  evidence 
of  fractures  of  the  base.  The  injury  may  be  primar^-^ — that  is,  the  nerve 
or  nerves  are  torn  opposite  the  line  of  fracture  at  the  moment  of  its 
production  or  are  torn  out  from  their  origins  at  the  surface  of  the  brain, 
owing  to  the  distortion  of  the  skull  which  results  from  the  injury;  or, 
on  the  other  hand,  the  nerves  are  involved  secondarily  by  the  pressure 
of  effused  products,  blood  or  inflammatory  exudations. 

The  first  pair  of  nerves  is  frequently  involved,  sometimes  directly  by 
a  fracture  passing  through  the  cribriform  plate,  but  more  often  probably 
as  the  result  of  force  appHedto  the  skull  at  a  distance,  producing  lacera- 
tion of  the  orbital  surface  of  the  frontal  lobes  and,  along  with  that, 


34  REGIONAL   SURGERY 

destruction  of  one  or  both  of  the  olfactory  bulbs  and  tracts.     With  loss 
of  smell  there  is  generally  a  varying  degree  of  loss  of  taste. 

The  optic  nerves  are  injured  either  directly  or  indirectly.  In  the 
former  case  the  nerve  or  optic  tract  maybe  actually  divided;  in  the  latter 
it  is  generally  compressed  by  blood  or  by  displaced  bone  (possibly  this 
is  due  to  fracture  of  the  anterior  clinoid  process  and  subsequent  dis- 
placement of  the  fragment) .  The  effect  may  be  a  total  or  partial  loss 
of  vision  which  results  immediately,  or  develops  only  later  on  in  the 
course  of  the  case;  though,  as  many  of  the  patients  are  unconscious  for 
considerable  periods  of  time  after  the  accident,  evidence  of  the  injury 
to  the  nerve  may  not  be  forthcoming  for  some  days. 

Injury  to  the  optic  tract  is  of  course  followed  by  hemianopia. 

Partial  loss  of  vision  may  result  from  retinal  hemorrhages  with 
subsequent  retinal  changes,  or  from  separation  of  the  retina. 

The  third  nerve  may  be  involved  directly  in  cases  of  direct  fractures 
of  the  orbital  roof,  by  the  penetrating  object  which  causes  the  fracture, 
or  by  fractures  of  the  sphenoid  bone;  but  more  often  its  function  is 
interfered  with  by  blood  extravasations,  or  by  infective  processes  at  the 
base  of  the  brain.  Like  the  other  nerves  in  relation  to  the  cavernous 
sinus  it  is  liable  to  be  involved  in  cases  of  pulsating  exophthalmos,  or  of 
thrombosis  of  the  sinus. 

Symptoms. — Ptosis;  external  strabismus;  mydriasis;  loss  of  accom- 
modation; slight  exophthalmos. 

The  fourth  nerve  is  only  rarely  affected  without  some  of  the  other 
nerves  of  the  orbit  being  involved. 

Symptom. — Defective  movement  of  the  eye  downward  and  out- 
ward due  to  paralysis  of  the  superior  oblique. 

The  fifth  nerve  also  is  generally  affected  in  association  with  some 
other  cranial  nerves.  The  second  and  third  divisions  are  very  rarely 
interfered  with,  permanently  at  any  rate.  The  first  division  is  occasion- 
ally affected,  leading  to  anesthesia  of  the  areas  supplied  by  it,  and, 
more  important  still,  as  the  result  of  the  anesthesia  of  cornea  and  con- 
junctiva, to  sloughing  or  ulceration  of  the  cornea.  The  writer  has  several 
times  seen  herpetic  eruptions  over  parts  supplied  by  one  or  other  of  the 
branches  of  the  fifth  nerve,  although  there  was  no  evidence  of  paralysis, 
and  believes  that  these  eruptions  were  evidence  of  disturbance  of  the 
nerve  fibers  by  hemorrhage. 

The  sixth  nerve  is  not  often  affected  in  head  injuries,  in  spite  of  its 
close  relation  to  the  apex  of  the  petrous  bone  and  to  the  dorsum 
ephippii,  but  is  sometimes  involved  by  exudations  at  the  base  of  the 
skull. 


TRAUMATA  OF  THE  SKULL  AND  CONTENTS  35 

The  seventh  or  facial  nerve  is  probably  more  frequently  involved  than 
any  of  the  other  cranial  nerves;  the  effect  may  be  partial  or  complete, 
transient  or  permanent.  The  cases  of  permanent  and  complete  paral- 
ysis are  usually  associated  with  complete  deafness  and  are  due  to  lacer- 
ation of  the  nerve  in  the  Fallopian  aqueduct;  while  the  cases  of  partial 
paralysis  are  most  frequently  the  result  of  exudation  compression,  and 
generally  develop  a  day  or  two  after  the  accident.  The  muscles  sup- 
phed  by  the  seventh  nerve  are  at  times  paralyzed  owing  to  the  cortical 
center  being  injured  or  compressed;  in  these  cases  the  muscles  of  the 
upper  part  of  the  face  are  often  spared.  With  complete  facial  paralysis 
there  may  be  ulceration  of  the  cornea,  epiphora,  and  disturbance  of 
mastication. 

The  eighth  nerve  is  rarely  involved  alone,  but  may  be  torn  at  the 
porus  acusticus  without  the  seventh  nerve's  being  affected,  when 
permanent  and  complete  deafness  on  the  side  of  the  tear  is  the  result. 
Permanent  deafness  may  also  result  from  injuries  to  the  labyrinth. 
Blood  in  the  tympanum,  or  rupture  of  the  membrane  with  injury 
to  the  ossicles,  will  cause  some  interference  with  hearing;  and,  even 
though  it  is  not  absolute,  it  is  often  serious  <    ough  to  the  patient. 

The  ninth,  tenth,  eleventh  and  twelfth  nerv(  >  rarely  manifest  evidence 
of  their  involvement,  and  only  a  few  cases  are  on  record  of  direct 
injuries  to  any  of  them;  but  secondary  compression  which  is  recovered 
from,  is  not  altogether  rare.  One  frequently  sees  patients  with  marked 
difficulty  in  swallowing,  after  injuries  to  the  head,  where  there  is  reason 
to  believe  there  is  blood  extravasted  near  these  nerves. 

The  prognosis  in  skull  fractures  depends  chiefly  upon  the  intra- 
cranial complications  that  may  be  associated  with  them,  i.e.,  lacerations 
of  blood-vessels,  or  the  spread  of  infection. 

If  infection  can  be  prevented,  and  if  the  brain  is  uninjured,  most 
cases  recover.     The  first  twenty-four  hours  is  the  most  critical  period. 

Open  fractures  are  necessarily  more  serious  than  closed  ones; 
which  fact  explains  in  part  why  fractures  of  the  base  are  generally 
speaking  more  serious  than  vault  fractures.  Basal  fractures  as  a  rule 
are  the  result  of  greater  violence,  more  diffused  at  any  rate,  than  vault 
fractures,  and  are  more  often  associated  with  contusions  and  lacera- 
tions of  the  brain,  and  are,  therefore,  more  often  followed  by  signs  of 
compression  of  the  brain. 

The  union  of  fractures  of  the  skull  takes  place  readily  as  a  rule. 
Callus  tends  to  form  more  on  the  internal  aspect  of  the  skull  than  on 
the  external — from  the  dura  mater  rather  than  from  the  pericranium. 


7,6  REGIONAL   SURGERY 

In  consequence  of  the  internal  table's  fracturing  more  widely  than  the 
external  and  its  fragments  being  often  displaced,  osteophytic  develop- 
ments take  place  which  in  certain  instances  lead  to  irritation  of  the 
brain  beneath,  and  this  may  have  serious  consequences  for  the  patient. 
Depressed  fractures  of  the  vault  are  specially  prone  to  this  development 
of  osteophytes. 

Punctured  fractures  of  the  skull  are  of  the  greatest  importance,  for 
the  internal  table  is  always  more  extensively  fractured  than  the  ex- 
ternal, and  some  bone  fragments  are  often  carried  into  the  cranial 
cavity.  The  brain  and  membranes  are  not  only  very  frequently 
directly  injured,  but  may  have  infective  material  carried  directly  into 
their  substances,  for  these  are  practically  open  injuries. 

With  elevated  fractures  of  the  vault  the  prognosis  is  mainly  de- 
pendent upon  the  presence  or  absence  of  injury  to  the  brain.  The 
bone  flap,  as  a  rule,  unites  readily  when  brought  into  its  correct  position. 

The  Treatment  of  Fractures  of  the  Skull. — Patients  suffering  from 
these  injuries  require  to  be  kept  quiet  and  warm.  Shock  effects  must 
be  combated. 

Closed,  or  subcutaneous  fissures  of  the  vault  may  be  left  without 
operation  until  signs  calling  for  trephining  arise.  The  writer  is  strongly 
of  opinion  that  all  cases  of  depressed  fracture,  whether  closed  or  open, 
require  operation  for  the  purpose  of  readjusting  the  fragments  to  their 
proper  level  and  plane. 

In  the  case  of  open  fractures  of  the  vault  too  much  care  cannot  be 
given  to  the  thorough  cleansing  of  the  wound.  The  margins,  and 
frequently  the  whole  surface,  of  the  wound  of  the  scalp  may  be  excised; 
all  dirt  particles  must  be  scrupulously  removed;  bone  ingrained  with 
dirt  requires  to  be  chiselled  off;  it  is  frequently  necessary  to  go  down  to 
the  level  of  the  diploe  to  get  rid  of  all  the  infected  bone;  and  in  the  case 
of  open  fissures  of  the  vault  the  whole  line  of  the  fissure  exposed  should 
be  chiselled  out,  often  down  to  the  dura  mater  level;  for  between  the 
closed  margins  of  these  fissures;  hairs  and  dirt  of  all  kinds  will  at  times 
be  found  concealed. 

Loose  fragments  of  bone  should,  as  far  as  possible,  be  cleansed, 
placed  in  warm  saline  solution  till  required,  and  replaced  over  the  dura 
when  the  toilet  of  the  wound  is  complete.  Where  the  asepsis  is  all 
right  these  fragments  of  bone  heal  in,  but  to  secure  this  they  require  to 
be  covered  with  the  soft  parts.  In  the  case  of  closed  fractures  no 
difficulty  is  experienced  in  this  respect,  but  in  open  fractures  it  may  not 
be  easy  to  bring  the  margins  of  the  wound  together,  and  then  incisions 


TRAUMATA  OF  THE  SKULL  AND  CONTENTS  37 

of  relaxation  may  be  required,  or  a  flap  may  be  cut  from  the  scalp  to  cover 
the  bone  lesion. 

Where,  on  account  of  the  presence  of  sepsis,  reimplantation  of  the 
trephine  discs  or  bone  fragments  in  comminuted  fractures  cannot  be 
made,  it  will  sometimes  be  desirable  to  endeavor  to  give  protection 
to  the  brain  and  its  membranes  by  filling  in  the  gap  in  the  skull.  Vari- 
ous procedures  have  been  proposed  to  this  end.  Bone,  metal  plates, 
rubber  tissue,  celluloid  plates,  etc.,  etc.,  have  all  been  employed.  Of 
these,  celluloid  appears  to  the  writer  to  be  the  material  most  suitable. 
The  osteoplastic  method  of  Konig-Muller  has  much  to  recommend  it 
when  the  gap  is  so  placed  that  the  bone  in  the  neighborhood  can  be 
satisfactorily  cut,  i.e.,  where  there  is  a  diploe  present.  If  left  unpro- 
tected, such  gaps  in  the  skull  may  be  filled  in  by  bone  produced  by  the 
dura  mater,  but  this  is  an  extremely  rare  occurrence,  and  one  that 
cannot  be  relied  upon. 

All  punctured  fractures  require  immediate  trephining  for  the  reasons 
already  indicated. 

As  to  fractures  of  the  base  we  are  unfortunately  in  a  much  worse  po- 
sition as  regards  treatment.^  A  large  proportion  of  these  patients  have 
open  fractures  communicating  with  cavities  which  are  always  septic, 
and  where  little  can  be  done  to  make  them  less  so.  Urotropin  should 
be  administered  in  all  these  cases,  and  especially  when  there  is  an 
escape  of  cerebro-spinal  fluid.  The  less  done  in  the  way  of  attempt- 
ing to  cleanse  the  nose  and  auditory  meatus  in  these  cases,  the  better, 
probably. 

GUNSHOT  INJURIES  OF  THE  SKULL  AND  BRAIN 

The  effects  upon  the  skull  caused  by  the  impact  and  penetration  of 
a  bullet  are  determined  in  the  main  by  the  shape,  caliber  and  mo- 
mentum of  the  projectile,  and  the  distance  that  it  traverses  the  brain. 

The  modern  cased  bullet  of  small  caliber  loses  its  power  of  perforat- 
ing the  entire  skull  at  a  range  of  about  one  and  a  half  miles. 

At  a  range  of  about  2000  yards  the  skull  is  perforated,  the  wound  of 
entrance  presenting  a  greater  degree  of  injury  to  the  internal  table,  and 
the  exit  wound  a  greater  amount  of  injury  to  the  external  table. 

Fired  at  a  short  range  complete  disruption  of  the  scalp,  skull  and  its 
contents  is  produced,  the  fragments  being  scattered  in  all  directions;  if 

'  It  is  sometimes  wise  to  open  the  skull  as  if  for  hemorrhage  from  the  middle  meningeal 
artery  or  at  a  lower  level,  and  to  remove  enough  bone  so  that  a  rubber  tissue  drain  may 
be  placed  on  the  floor  of  the  skull  as  a  prophylactic  measure  against  infection  or  the  collec- 
tion of  effusions  at  the  base  of  the  brain.     {Editor.) 


38  REGIONAL   SURGERY 

the  bone  fragments,  however,  be  collected  and  put  together,  the  skull 
will  present  a  wound  of  entrance  and  of  exit  demonstrating  that  the 
skull  and  brain  are  first  of  all  perforated  by  the  bullet  and  that  the  dis- 
ruption takes  place  after  that.  In  experiments  the  skull  is  never  dis- 
rupted if  the  brain  is  first  removed  from  its  interior.  The  disruptive 
effect  is,  therefore,  caused  by  the  bullet's  acting  upon  the  brain;  the 
action  is  hydrodynamic. 

Between  these  two  results,  the  complete  disruption  and  the  two 
simple  ''hole  fractures,"  every  variation  may  be  met  with  depending 
upon  the  range  of  the  shot. 

At  50  yards  the  skull  is  shattered;  but  the  scalp  is  capable  of  holding 
the  fragments  of  bone  together  although  it  presents  wide  entrance 
and  exit  wounds. 

At  100  yards  the  wounds  of  entrance  and  exit  present  a  series  of 
fissures  radiating  meridian  wise  from  them  (bursting-fractures),  joined 
by  fissures  (bending-fractures)  circling  the  hole-fracture  in  the  center. 

At  about  800  yards  the  bending-fractures  disappear  and  only  the 
bursting-fractures  persist. 

At  long  ranges  the  injury  to  the  brain  is  restricted  to  the  formation  of 
a  tunnel  through  its  substance  with  condensation  of  the  tissue  in  the 
walls  of  the  canal.  At  shorter  distances,  but  where  disruption  still  does 
not  follow,  the  dura  mater  and  the  brain  show  lacerations  and  the  brain 
has  hemorrhages  scattered  throughout  its  substance  while  the  ventricles 
contain  blood  or  blood-stained  fluid.  If  a  bullet  meets  the  skull  at  a 
tangent  an  impression  fracture  (gutter  fracture)  may  result,  the  external 
table  being  sometimes  carried  away  leaving  the  internal  table  depressed 
and  splintered,  generally  over  a  greater  area  than  that  of  the  external, 
and  very  frequently  spicules  are  driven  into  the  substance  of  the  brain. 
In  other  cases  a  portion  of  the  skull  wall  may  be  shot  away,  fissures,  ra- 
diating off  into  the  surrounding  bone,  being  produced  at  the  same- 
time.  In  other  instances  a  fracture  of  the  internal  table  alone  may  be 
produced. 

Pistol  shots  cause  wounds  with  radiating  (bursting)  and  concentric 
(bending)  fissures  around  the  entrance  wound,  and  the  wound  of  exit  as 
well,  if  there  be  one;  but  commonly  the  bullet  lodges  in  the  brain  and 
does  not  perforate  the  skull. 

Bullet  fractures  of  the  base  of  the  skull  are  of  great  importance  on 
account  of  their  proximity  to  the  medullary  region,  and  because  of  the 
injury  to  large  blood-vessels  within  the  skull  that  so  often  happens  in 
these  cases.     In  those  cases  which  are  not  immed'ately  fatal,  the  effect 


TRAUMATA  OF  THE  SKULL  AND  CONTENTS  39 

of  the  bullet  wound  is  to  cause,  rapidly,  symptoms  of  compression  of  the 
brain  from  hemorrhage.  There  may  be  localized  irritative  or  paralytic 
signs  associated,  which  are  often  due  to  the  direct  injury  to  definite 
areas  of  the  brain  during  the  transit  of  the  bullet. 

Prognosis  depends  upon  the  caliber  and  momentum  of  the  bullet  and 
the  region  of  the  brain  involved.  It  is  markedly  influenced  by  the 
presence  of  sepsis. 

Treatment. — One's  object  should  be  to  (i)  arrest  hemorrhage,  (2) 
afford  free  drainage,  (3)  maintain  asepsis,  (4)  inflict  as  little  injury 
upon  the  brain  as  possible  in  securing  these  results.  Where  there  is 
splintering  of  bone  and  fragments  are  driven  into  the  brain  they  should 
be  removed;  depressed  bone  must  be  elevated;  and,  if  necessary,  the 
original  wound  may  be  enlarged  to  relieve  tension  and  permit  drainage 
of  blood,  blood-clot  and  bruised  brain  tissue.  Where  comminution  of 
bone  does  not  exist,  primary  trephining  is  not  generally  required  unless 
there  be  severe  compression  or  Jacksonian  convulsions.  Attempts  to 
remove  the  bullet  ought  not  to  be  made  in  the  first  instance  as  it  may 
become  encapsuled  and  give  no  trouble  at  all.  When  a  bullet  does 
give  rise  to  trouble  its  removal  may  be  attempted  after  it  has  been 
localized  by  X-ray  examination  carried  out  immediately  before  the 
operation  in  at  least  two  diameters  of  the  skull.  The  after-eft'ects  of 
bullet  wounds  of  the  brain  are  quite  frequently  due  to  scarring  of  the 
brain  rather  than  to  the  actual  presence  of  the  bullet  so  that  the  suc- 
cessful extraction  of  the  latter  may  result  in  little  benefit  for  the 
patient. 

Concussion  of  the  Brain  {''Cerebral  Commotion"). — This  state,  so 
often  seen  after  head  injuries,  is  the  consequence  of  the  application  of 
sudden  and  diffused  violence  to  the  skull.  It  is  remarkable  that  in  a 
very  large  number  of  cases  of  injuries  to  the  skull,  often  severe  in  them- 
■selves  but  caused  by  violence  localized  to  one  area,  all  signs  of  concus- 
sion are  absent;  and  one  frequently  sees  cases  of  local  depressed  frac- 
tures of  the  skull  where  the  patient  has  not  manifested  any  evidence  of 
concussion  whatever. 

The  accidents  which  most  certainly  produce  concussion  symptoms 
are  those  by  which  the  skull  and  brain  are  suddenly  knocked  into 
motion,  e.g.,  by  a  blow  upon  the  freely  movable,  unsupported  head; 
or  where,  as  in  a  fall  from  a  height,  the  moving  head  is  suddenly  arrested 
by  any  object  of  suflicient  resisting  power  to  produce  a  jarring  of  the 
skull  and  its  contained  brain. 

The  symptoms  recognized  as  those  of  concussion  are  the  result  of  a 


40  REGIONAL   SURGERY 

general  commotion  of  the  brain  substance  by  the  vibrations  set  up  in  it 
in  consequence  of  the  injury. 

It  is  extremely  rare  to  find,  at  a  post-mortem  examination  of  a 
patient  dead  after  a  head  injury,  no  evidence  of  damage  to  the  brain; 
minute  hemorrhages  scattered  throughout  the  brain  substance  are  seen 
macroscopically  in  almost  every  case,  while  histologically  there  is  very 
constant  evidence  of  chromatolysis  and  vacuolation  of  the  nerve  cells. 

But  there  are  undoubtedly  authentic  records  of  cases  of  concussion 
where  no  cerebral  lesions  have  been  macroscopically  obvious  at  post- 
mortem examination. 

The  state  of  "concussion  of  the  brain"  is  one  of  "shock"  and  like 
other  cases  of  shock  is  due  to  a  sudden  diminution  of  the  vasomotor 
activity,  with  anemia  of  the  brain  as  the  result. 

Duret  and  his  followers  have  argued  that  as  the  consequence  of  the 
blow,  cerebro-spinal  fluid  is  suddenly  displaced  from  the  ventricles  and 
forced,  suddenly,  into  the  fourth  ventricle  through  the  iter,  and  that 
stimulation  of  the  vasomotor  centers  results  from  the  damage  done  to  the 
floor  of  the  fourth  ventricle  which  is  manifested  by  small  hemorrhages 
in  the  brain  substance  at  this  a^-ea.  In  the  writer's  experience  these 
hemorrhages  are  remarkable  for  their  absence  in  those  cases  of  head 
injury  that  come  to  post-mortem  examination. 

Kocher  and  his  followers  consider  the  condition  to  be  one  of  "acute 
brain-pressure"  (acuter  Hirn-druck),  the  result  of  the  minute  hemor- 
rhages throughout  the  brain;  but  it  is  difficult  to  conceive  that,  in  the 
slight  and  actually  the  clinically  "typical"  cases  of  "concussion,"  such 
hemorrhages  can  be  present,  and  yet  the  patients  recover  consciousness 
as  rapidly  as  they  do. 

Symptoms. — Extraordinary  variations  in  the  degrees  of  severity  of 
concussion  are  met  with.  A  patient  may  die  from  the  result  of  concus- 
sion, though  this  is  a  rare  occurrence.  Another  patient  is  merely 
rendered  giddy  by  the  violence,  has  a  momentary  loss  of  consciousness, 
some  mental  confusion,  and  quickly  recovers:  and  between  these  two 
types,  the  slightest  and  the  severest,  every  degree  of  concussion  may  be 
seen.  The  symptoms  of  concussion  can  merge  into  those  of  compres- 
sion or  of  laceration  of  the  brain,  but  they  are  invariably  immediate  in 
their  onset;  when  there  is  anything  of  the  nature  of  a  "lucid  interval" 
following  the  injury  the  symptoms  that  develop  are  due  to  some  other 
state  than  concussion. 

In  typical  cases  a  patient  who  is  "concussed"  falls  to  the  ground 
unconscious,  the  face  is  pale,  the  eyes  closed  or  half-open,  the  con- 


TRAUMATA   OF   THE    SKULL   AND    CONTENTS  4I 

junctival  reflex  is  generally  absent,  the  pupils  are  wide  or  of  medium 
size,  but  are  not  contracted,  the  pulse  is  slow  and  small,  respiration  is 
shallow  and  not  uncommonly  sighing.  There  is  general  relaxation  of 
the  muscular  system  and  very  frequently  both  urine  and  faeces  are 
voided  unconsciously.  The  skin  is  moist  with  sweat  and  the  general 
body  temperature  is  lowered.  When  one  shouts  at  the  patient  he  may 
or  may  not  be  able  to  give  monosyllabic  replies. 

A  patient  may  remain  unconscious  for  hours,  certainly,  perhaps  for 
days,  and  still  recover,  but  the  longer  he  remains  unconscious  the  less 
Hkehhood  is  there  of  the  condition  being  one  of  simple  concussion. 

In  cases  of  pure  concussion  the  patients  gradually  recover  conscious- 
ness, they  frequently  vomit,  become  restless,  and  complain  of  headache 
or  pains  throughout  the  body  and  limbs;  the  frequency  and  force  of  the 
heart-beat  return,  the  body  heat  is  restored  and,  by  degrees,  all  the 
symptoms  pass  off. 

A  patient  who  has  been  "concussed"  very  generally  has  complete 
loss  of  memory  for  all  events  at  the  time  of  the  injury  and  frequently  for 
some  time  previous  to  it. 

Treatment. — Warmth  for  the  patient  is  the  great  desideratum.  Hot 
drinks  when  he  can  swallow.  The  head  may  be  lowered  in  bad  cases; 
and  a  firm  binder,  applied  round  the  abdomen,  and  bandages  to  the 
limbs  may  be  a  help.  The  intravenous  injection  of  saline  and  artificial 
respiration  may  be  necessary  in  some  of  the  severe  cases. 

Calomel  or  some  other  purgative  should  be  given  as  soon  as  the 
patient  can  swallow. 

Every  patient  rendered  unconscious  by  a  blow  upon  the  head  should 
be  kept  quiet  in  bed  for  at  least  four  weeks  afterward,  as  thereby 
various  neuroses  to  which  these  patients  are  liable  are  most  completely 
avoided. 

Compression  of  the  brain  may  exist  in  two  forms:  localized  and 
general.  The  former  is  seen  in  cases  of  middle  meningeal  and  extra- 
dural hemorrhage,  oedema,  tumor,  abscess  or  foreign  body;  the  latter 
in  subdural  diffuse  hemorrhage,  and  in  meningitis. 

As  a  complication  of  fracture  of  the  skull  compression  symptoms 
may  be  brought  about  by  (i)  depressed  bone,  (2)  effused  blood,  (3) 
oedema  of  the  brain  and  membranes,  (4)  inflammatory  exudations. 

The  theory  most  generally  accepted  regarding  the  production  of 
compression  is  that  the  brain  itself  is  incompressible  and  that  symptoms 
are  brought  about  only  by  a  rise  of  the  tension  of  the  cerebro-spinal 
fluid.     Normally  the  cerebro-spinal  fluid  can  be  displaced  and  escape 


42  REGIONAL  SURGERY 

into  the  spinal  canal  and  nerve  sheaths,  or  into  the  blood-vessels.  If 
the  pressure  in  the  veins  or  sinuses  is  raised,  as  happens  with  increase  of 
intracranial  tension,  one  means  of  exit  is  blocked.  The  other  may  also 
be  blocked  through  translocation  downward  of  the  brain  so  that  the 
isthmus  through  the  tentorium  becomes  obstructed,  and  the  cerebro- 
spinal fluid  is  prevented  from  escaping  into  the  spinal  canal. 

Within  the  last  few  years  the  proposition  put  forward  in  1890  by 
Adamkiewicz,  that  pathological  increase  of  the  tension  of  the  cerebro- 
spinal fluid  does  not  occur,  and  that  the  brain  tissue  is  directly  com- 
pressed (condensed),  has  been  receiving  attention;  and  the  results  of 
some  experimental  work  carried  out  by  several  observers  have  been 
published  in  support  of  it. 

That  there  is  an  increase  in  the  tension  of  the  cerebro-spinal  fluid  is 
certain  from  clinical  experience.  During  the  course  of  operations  for 
compression  following  upon  trauma  the  fluid  often  spouts  like  a  small 
fountain  when  the  dura  mater  is  divided;  and  conversely  after  a  trauma 
producing  a  localized  extradural  hemorrhage  even  of  large  dimensions, 
all  symptoms  of  compression  may  remain  in  abeyance  if  the  cerebro- 
spinal fluid  can  escape  to  the  exterior  through  a  fracture  {e.g.,  of  the 
petrous  bone),  and  escape  through  the  auditory  meatus.  But  the 
brain  tissue  itself  may  be  compressed  in  cases  of  fracture  with  extra- 
dural hemorrhage,  for  it  will  occasionally  happen  that  after  an  operation 
at  which  all  clot  has  been  removed,  the  patient  nevertheless  succumbs, 
and  at  post-mortem  examination  it  is  found  that  the  brain  is  still  com- 
pressed locally  beneath  the  site  of  the  clot. 

It  is  probable  that  in  the  average  type  of  compression  case  without 
an  external  escape  of  cerebro-spinal  fluid,  the  general  symptoms  of 
compression  are  the  result  of  the  increase  of  the  tension  of  the  fluid,  but 
that  the  localizing  symptoms,  e.g.,  the  hemiplegia  following  an  extra- 
dural clot,  are  caused  by  the  local  pressure  upon  the  brain  tissue  itself. 
It  has  been  shown  experimentally  that  while  compression  symptoms 
can  be  produced  with  a  free  escape  of  cerebro-spinal  fluid,  it  requires 
much  greater  pressure  to  do  so  than  when  the  fluid  is  confined. 

As  the  tension  of  the  fluid  is  increased  it  tends  to  cause  an  anaemia 
of  the  brain.  When  a  localized  compression  occurs  that  area  of  the 
brain  beneath  the  compressing  agent  (clot),  or  round  it  (abscess  or 
tumor)  has  the  blood  expressed  from  its  vessels  and  again  anaemia — local 
this  time — is  produced — "Adiamorrhysis." 

A  considerably  greater  pressure  is  required  in  the  cerebral  supra- 
tentorial  cavity  than  in  the  cerebellar  infratentorial  space  to  cause 


TRAUMATA   OF   THE    SKULL   AND    CONTENTS  43 

symptoms;  while  in  the  region  of  the  medulla  the  pressure  requires  only 
to  be  very  little  above  that  of  the  capillaries  to  produce  fatal  results. 

In  cases  of  pure  compression  the  medullary  centers  are  the  all-impor- 
tant ones  and  their  reaction  to  the  effects  of  the  compressing  agent  is 
remarkable.  The  first  effect  is  one  of  irritation  or  stimulation.  The 
vasomotor,  the  respiratory  and  vagus  centers  each  are  affected.  The 
blood  pressure  rises,  the  tension  of  the  pulse  is  greatly  increased,  the 
heart  is  slowed,  and  the  respiratory  act  becomes  somewhat  irregular  as 
to  depth  and  rhythm.  With  the  rise  of  blood  pressure  thus  produced 
these  centers  again  become  better  supplied  with  blood  and  their  activ- 
ity is  eased  off.  With  a  further  rise  of  intracranial  tension  cerebral 
anaemia  is  again  produced  and  again  results  in  stimulation,  and  once 
more  the  blood  pressure  rises  to  "force  the  cerebral  circulation;"  this 
cycle  may  occur  several  times,  until  the  vasomotor  center  ultimately 
becomes  exhausted  and  gives  out,  and  the  symptoms  of  compression 
progress. 

Death  takes  place  from  paralysis  of  the  respiratory  center,  the  onset 
of  which  is  indicated  by  the  development  of  Cheyne-Stokes  respiration. 
The  heart  may  continue  to  beat  for  some  considerable  time  after  all 
respiratory  efforts  have  come  to  an  end. 

With  a  circumscribed  compression  a  localized  anaemia  is  brought 
about  at  that  area  but  the  compression  on  the  veins  of  surrounding  parts 
ofthe  brain  is  increased  and  venous  obstruction  results,  to  be  followed 
by  oedema  of  the  brain  and  soft  membranes  around  the  anaemic  zone; 
and,  in  consequence  of  this,  centers  of  the  brain  at  a  distance  from  the 
actually  compressed  area  may  be  involved  and  cause  symptoms,  e  g., 
epileptiform  convulsions  may  be  produced  by  involvement  of  the  motor 
centers  in  this  manner. 

In  the  rapidly  developing  compression  of  the  brain  with  which  we 
have  specially  to  do  in  traumatic  cases  the  gray  matter  of  the 
cortex  is  always  the  first  to  suffer;  and  at  a  time  when  the  effect  of  the 
compressing  agent  is  to  paralyze  its  functions,  the  more  automatic 
centers  of  the  medulla  may  only  evidence  irritative  signs. 

The  symptoms  of  compression  may  be  divided  into  two  types,  irri- 
tative and  paralytic. 

The  irritative  symptoms  manifest  themselves  by  headache,  some 
mental  dullness,  restlessness,  vomiting,  rapid  pulse  and  respiration,  the 
respiratory  acts  being  often  irregular  at  first.  There  are  narrowing  of 
the  pupil,  and  edema  of  the  optic  discs  and  retina. 

Progressive  loss  of  consciousness,  loss  of  the  superficial  reflexes,  with 


44  REGIONAL   SURGERY 

slowing  of  the  pulse,  which  later  on  becomes  full  and  hard,  "bounding;" 
slowing  of  the  respiratory  movements  with  deeper  action  and  often 
associated  with  stertor;  dilatation  of  the  pupils,  loss  of  the  deep 
reflexes;  often  excessive  sweating,  retention  of  urine  followed  by 
overflow,  involuntary  evacuation  of  the  bowel,  indicate  the  progressive 
character  of  the  symptoms  and  the  onset  of  paralytic  phenomena. 
This  is  the  stage  of  "manifest  compression"  with  complete  coma. 

With  increase  of  the  intracranial  tension  there  is  further  evidence 
of  paralysis;  slowing  of  the  pulse  and  respiration  gives  way  to  a  marked 
increase  in  frequency,  the  pulse  becomes  soft  and  small,  the  respirations 
occur  in  cycles  (Cheyne-Stokes  breathing)  there  is  still  further  dilata- 
tion of  the  pupils,  marked  cyanosis,  fall  of  the  blood  pressure,  and 
death  from  paralysis  of  the  respiratory  center. 

During  the  progress  of  the  case  there  may  be  signs  of  localized  pres- 
sure upon  the  brain,  e.g.,  paralysis  of  ocular  muscles  or  a  contralateral 
paralysis  of  one  or  both  limbs,  or  complete  hemiplegia.  In  some  cases 
convulsions  occur.  The  body  temperature  is  often  low,  but  in  many 
cases  is  markedly  elevated. 

In  the  diagnosis  from  concussion  the  state  of  the  pulse,  respiration 
and  optic  discs  are  most  important  guides,  when  there  is  the  absence  of  a 
history  of  a  lucid  interval.  Compression  symptoms  generally  require 
time  for  their  development  and  quite  frequently  are  superadded  to  those 
of  concussion.  Inequality  of  pupil,  or  a  pupil  which  does  not  react  to 
light,  points  to  compression. 

A  complete  examination  of  the  patient  is  always  necessary  in  sus- 
pected cases,  and  very  particularly  in  cases  of  coma  where  a  history  of 
trauma  is  not  forthcoming. 

Alcoholic  coma  is  probably  the  condition  most  often  in  view,  and,  as 
alcohol  is  so  frequently  responsible  for  the  injury  producing  the  head 
condition,  difficulty  not  uncommonly  arises.  The  pupils  afford  the 
characteristic  feature;  for  in  compression  of  any  considerable  degree 
they  are  always  dilated,  whereas  in  alcoholic  coma  they  are  pin-point; 
but  they  dilate  if  the  patient  be  roused,  returning  very  gradually  to  their 
contracted  state  when  the  patient  is  left  at  rest  (the  "Macewen  pupil"). 
The  temperature  is  generally  subnormal  in  alcoholic  coma. 

In  the  coma  of  uraemia,  diabetes  or  opium  the  odor  of  the  breath  will 
sometimes  help;  it  is  sweetish  in  uraemia,  acetone-  or  chloroform-like  in 
diabetes,  and  has  a  peculiarity  of  its  own  in  opium  poisoning.  Exami- 
nation of  the  fundus  of  the  eyes  should  always  be  carried  out  to  deter- 
mine the  presence  or  absence  of  retinitis,  neuritis  or  atrophy  of  the  disc. 


TRAUMATA    OF   THE    SKULL   AND    CONTENTS  45 

In  opium  poisoning  the  pupils  are  pin-point  and  non-responsive.  In 
diabetic  coma  they  are  dilated  but  react;  and  in  uraemic  coma  they  are 
dilated  and  react  slowly. 

The  prognosis  depends  upon  the  nature  of  the  compressing  agent,  its 
volume  and  the  length  of  time  it  has  been  acting  and  whether  it  can  be 
removed  or  not.  When  depressed  bone  is  responsible,  its  elevation  or 
removal  is  usually  rapidly  followed  by  disappearance  of  the  symptoms. 
Blood-clot  or  pus,  if  either  has  been  the  compressing  agent  and  acting  for 
some  time,  may,  even  if  removed,  have  led  to  such  changes  in  the  brain 
at  the  site  of  compression  that  it  does  not  recover  itself. 

Diffused  compressing  agents  such  as  effused  blood,  oedema  of  the 
membranes,  and  infective  meningitis  are  usually  fatal. 

The  treatment  is  to  be  carried  out  by  removal  of  the  cause  by  opera- 
tive measures  whenever  that  is  possible. 

THE    COMPLICATIONS    OF    FRACTURES    OF    THE    SKULL 

Hemorrhage  from  the  meningeal  vessels  may  be  either  extra-  or 
intradural  or  both.  Extradural  hemorrhage  takes  place  either  from  the 
arteries  or  the  venous  sinuses  of  the  dura  mater;  in  some  instances 
where  rupture  of  the  dura  mater  takes  place,  blood  is  found  both  outside 
and  inside  the  dura  (the  "epanchement  en  bissac");  but  extradural 
bleeding  from  the  sinuses  is  rare;  hemorrhage  from  this  source  almost 
always  takes  place  into  the  subdural  space. 

The  middle  meningeal  artery  enters  the  skull  by  the  foramen  spin- 
osum  and  divides  into  two  branches,  the  anterior  and  posterior;  the 
former  curves  upward  and  then  turns  backward  over  the  meninges 
covering  the  frontal  lobe,  while  the  latter  runs  backward  and  upward 
toward  the  parietal  eminence.  The  vessel  is  probably  usually  torn 
across  by  fissures  of  the  bone  passing  over  it.  But  it  may  be  ruptured 
without  any  fracture  at  all,  or  without  any  fracture  in  the  immediate 
neighborhood  of  the  vessel.  These  cases  are  the  result  of  the  deform- 
ity of  the  skull  that  is  caused  at  the  moment  of  application  of  the  vio- 
lence, for  the  dura,  being  less  elastic  than  the  skull,  does  not  react  so 
rapidly  and  is  separated  from  the  bone,  and  the  artery  gets  lacerated. 
In  rare  instances  hemorrhage  has  occurred  on  both  sides  of  the  skull,  the 
two  arteries  being  injured  directly  by  fractures  of  the  bone  over  them; 
or  in  other  cases  by  a  fracture  on  one  side  and  separation  of  the  dura  on 
the  other. 

It  is  not  clear  always  from  where  the  hemorrhage  actually  takes 
place — the  trunk,  the  anterior  or  the  posterior  branch  of  the  artery.     In 


46  .  REGIONAL   SURGERY 

the  writer's  experience  the  anterior  branch  and  the  trunk  have  been  more 
often  injured  than  has  the  posterior  branch.  Small  thin  clots  (found 
at  post-mortem  examinations)  result  from  tearing  of  minute  twigs  and 
probably  give  rise  to  no  serious  symptoms. 

In  ordinary  cases  when  once  the  vessel  is  torn  and  the  escape  of  blood 
started,  the  bleeding  will  continue  until  thrombosis  occurs,  or  the  pres- 
sure within  the  skull  reaches  that  inside  the  artery;  but  it  occasionally 
happens,  when  a  fracture  of  the  bones  over  or  near  the  artery  exists,  that 
a  gaping  of  the  margins  of  the  fracture  is  present,  so  that  the  blood  has  a 
free  exit  from  the  interior  of  the  skull  and  forms  an  extracranial  temporal 
hematoma  which  can  reach  a  considerable  size,  and  of  course  if  a  wound 
of  the  soft  parts  over  this  be  present,  the  blood  can  escape  externally  and 
continuously. 

These  meningeal  hemorrhages  have  been  classified  as  diffuse  or 
circumscribed. 

The  diffuse  hematoma  may  extend  over  practically  one-half  of  the 
cerebrum. 

The  circumscribed  variety  has  been  further  subdivided  into  the 
fronto-temporal,  temporo-parietal,  parieto-occipital,  occipital  .and 
sphenoidal;  and  of  these  the  temporo-parietal  is  the  type  most  fre- 
quently met  with.  The  amount  of  clot  found  may  be  anything  up  to 
9  ounces.  From  some  extremely  rare  cases  it  would  appear  that  an 
extradural  clot  of  some  magnitude  may  undergo  absorption,  but  this  is 
so  rare  that  it  ought  never  to  be  looked  for;  and  a  clot  left  to  absorb 
may  at  any  time  become  the  seat  of  infection.  The  writer  believes 
that  small,  thin  clots  as  described  above  do  not  cause  symptoms,  and 
that  these  probably  are  frequently  absorbed.  Under  still  rarer  condi- 
tions, probably,  an  aneurism  may  result  from  a  rupture  of  the  artery. 

The  Symptoms. — In  a  typical  case  of  middle  meningeal  hemorrhage 
there  is  (i)  a  period  of  unconsciousness  following  immediately  upon  an 
injury  to  the  head;  this  is  the  result  of  cerebral  concussion,  and  it  is  a 
stage  which  lasts  a  varying  length  of  time.  It  is  followed  by  (2)  a  pe- 
riod of  more  or  less  complete  consciousness  (the  so-called  "lucid  inter- 
val") and  this  is  in  turn  succeeded  by  (3)  a  state  of  unconsciousness, 
gradual  in  its  onset  and  ushered  in  by  headache,  vomiting,  drowsiness, 
often  followed  by  signs  of  localized  pressure  upon  the  brain,  coma,  and 
the  typical  signs  of  "compression." 

Great  importance  is  attached  to  the  "lucid  interval"  as  an  aid  to  the 
diagnosis  of  a  hemorrhage  from  this  source.  Jacobson  found  it  present 
in  50  per  cent.,  and  Weissmann  in  55  per  cent,  of  his  collected  series  of 


TRAUMATA   OF   THE    SKULL   AND    CONTENTS  47 

257  cases.  It  should  always  be  inquired  for  in  any  suspected  case;  but 
it  may  never  be  present  at  all,  generally  because  of  injury  to  vessels 
within  the  dura  mater  at  the  time  the  meningeal  artery  was  ruptured,  in 
consequence  of  which  rapid  compression  is  brought  about.  In  some 
cases  (they  are  uncommon)  compression  signs  may  be  present  from  the 
outset  as  the  result  of  depressed  bone.  In  another  class  of  cases  the 
lucid  interval  may  not  be  recognized  owing  to  alcoholic  intoxication  of 
the  patient.  In  yet  another  class,  compression  signs  may  be  absent 
in  consequence  of  (i)  a  free  escape  of  blood  from  the  cranial  cavity  to  the 
exterior  through  a  fracture  as  indicated  already,  or  (2)  a  free  escape  of 
cerebro-spinal  fluid,  e.g.,  from  the  auditory  meatus. 

When  localized  compression  of  the  brain  is  brought  about,  it  almost 
invariably  is  in  the  form  of  a  contralateral  paralysis  the  upper  and 
lower  extremities  of  the  opposite  side  of  the  body  being  generally 
involved;  and,  while  paralysis  of  the  upper  limb  alone  is  met  with,  an 
isolated  paralysis  of  the  lower  limb  is  practically  never  seen. 

Twitchings  and  convulsive  movements  of  the  limbs,  occasionally  met 
with,  indicate  injury  below  the  dura  mater.  In  some  very  rare  cases 
collateral  paralysis  (paralysis  of  the  limbs  on  the  same  side  as  the  clot) 
has  been  recorded.  The  explanation  of  this  is  not  altogether  clear,  but 
it  is  probable  that  it  is  not  due  to  the  absence  of  decussation  of  the  py- 
ramidal tracts  as  some  observers  have  suggested. 

The  pulse  and  respiration  are  altered  in  accordance  with  the  state  of 
the  patient;  that  is,  during  the  early  concussion  state  the  pulse  tends  to 
be  small  and  quick,  while  respiration  is  shallow  and  sighing;  in  the  later 
stage  of  compression  the  pulse  is  slow  and  full,  and  the  respiration  slow 
and  deep  and  often  stertorous  in  character. 

Changes  are  to  be  observed  in  the  pupils  in  most  cases,  though 
unfortunately  they  are  by  no  means  constant.  Weissmann  in  his  series 
of  collected  cases  found  that  an  alteration  in  the  pupils  was  noted  in 
70;  in  39  of  these  both  pupils  were  wide  and  reactionless;  in  7  cases 
both  were  extremely  narrowed;  in  20  cases  the  pupil  on  the  same  side  as 
the  extravasated  blood  was  wide;  and  in  4  cases  it  was  so  on  the  side 
opposite  to  the  hemorrhage.  If  the  actual  state  of  the  pupils  does  not 
afford  much  help  from  the  diagnostic  point  of  view,  it  does  from  the 
prognostic  aspect;  for,  with  well-defined  signs  of  compression,  if  both 
pupils  are  wide  and  do  not  react,  the  degree  of  compression  is  almost 
certainly  great;  whereas  if  both  pupils  are  equal  and  react  to  light, 
the  compression  will  probably  be  recovered  from,  if  operation  be 
successful  in  removing  the  clot.     If  possible,  in  every  case  an  ophthal- 


48  REGIONAL   SURGERY 

moscopic  examination  of  the  fundus  of  the  eye  should  be  carried  out, 
when  evidence  of  obstruction  to  the  venous  return  may  be  obtained. 

Sensory  phenomena  are  seldom  observed,  probably  owing  to  the 
state  of  unconsciousness. 

The  bladder  and  rectum  are  variously  involved:  at  times  one  sees 
retention  of  urine  with  overflow;  at  others  spontaneous  though  uncon- 
scious evacuation  occurs.     Incontinence  of  fasces  is  common. 

The  diagnosis  of  this  condition  is  often  a  matter  of  the  extremest 
difficulty,  and  in  the  absence  of  a  definite  history  may  be  impossible 
until  an  exploratory  operation  is  made. 

In  patients  who  are  genuinely  suffering  from  the  effects  of  trauma, 
the  diagnosis  has  to  be  made  from  (i)  laceration  of  the  brain,  (2)  sub- 
dural hemorrhage,  (3)  hemorrhage  from  one  of  the  venous  sinuses  of  the 
dura  mater.  In  the  last-mentioned  condition  the  symptoms  may  be 
absolutely  identical  with  those  in  an  extradural  hemorrhage. 

In  subdural  hemorrhage  the  onset  of  compression  symptoms  is 
generally  immediate,  although  in  a  certain  number  of  patients  there  is  a 
distinct  history  of  a  "lucid  interval"  and  in  such  cases  the  diagnosis 
can  only  be  cleared  up  by  an  exploration.  Lumbar  puncture  in  these 
cases  will  at  times  help,  for  in  purely  extradural  hemorrhage  the  cere- 
bro-spinal  fluid  is  free  of  blood.  In  laceration  of  the  brain  the  symp- 
toms tend  more  to  the  irritative  than  to  the  paralytic  type,  the  latter 
being  more  characteristic  of  the  extradural  injury.  Fat  embolism  of 
the  brain  can  lead  to  a  series  of  symptoms,  identical  with  those  seen  in 
middle  meningeal  hemorrhage;  these  cases  are,  however,  very  rare  and 
practically  invariably  associated  with  a  fracture  of  one  of  the  long  bones. 

The  prognosis  must  always  be  grave;  it  may  be  stated  that  prac- 
tically every  patient  with  an  extradural  clot  of  any  magnitude  who  is  not 
operated  upon  will  die;  absorption  of  the  clot  with  recovery  is  so  rare 
that  one  must  never  wait  for  it.  Even  where  a  clot  has  been  success- 
fully removed,  death  often  follows:  in  some  cases  because  there  is 
injury  to  the  brain  or  its  vessels,  but  in  other  cases  because  the  brain 
fails  to  expand  again  and  compression  symptoms  persist  in  spite  of  the 
relief  of  the  actual  pressure  by  an  operation.  Weissman  out  of  257 
cases  found  90  per  cent,  died  who  were  not  operated  on,  and  of  those 
operated  on  67  per  cent,  lived;  out  of  the  total  257,  65  per  cent,  died 
within  the  first  24  hours. 

Treatment. — As  soon  as  the  diagnosis  of  extradural  hemorrhage  is 
suggested  by  the  signs  manifested  by  any  patient  who  has  received  an 
injury  to  the  skull,  the  artery  on  the  side  suspected  ought  to  be  exposed; 


TRAUMATA   OF   THE    SKULL  AND    CONTENTS  49 

and,  if  no  clot  is  found  there,  the  artery  on  the  other  side  should 
be  seen  also.  Clot  must  be  evacuated,  and  the  bleeding  artery 
tied  whenever  that  is  feasible.  Quite  frequently  no  bleeding  point  can 
be  found,  the  hemorrhage  is  an  "oozing,"  probably  from  many  small 
branches  of  the  vessel.  In  such  a  case  the  cavity  must  be  lightly  packed, 
the  packing  to  be  withdrawn  later  after  thrombosis  has  taken  place.  In 
some  rare  instances  where  primary  arrest  of  the  hemorrhage  has  not 
been  possible,  there  may  be  secondary  bleeding,  and  one  may  be  obhged 
to  Hgate  the  carotid  artery,  as  once  happened  in  the  writer's  practice. 

There  are  various  methods  of  locating  upon  the  exterior  of  the  skull, 
the  position  of  the  artery  within.  The  writer  has  always  found  the 
following  method  satisfactory.  At  any  point  between  i  and  23>^ 
inches  directly  posterior  to  the  external  angular  process  of  the 
frontal  bone,  draw  a  vertical  Hne  from  the  upper  border  of  the  zygo- 
matic process,  equal  in  length  to  the  distance  selected  from  the  angular 
process,  and  place  the  pin  of  the  trephine  on  the  skull  at  this  spot, 
for  the  anterior  branch  of  the  artery.  To  expose  the  posterior  branch 
the  skull  should  be  trephined  %  in.  behind  and  ^^  in.  below  the  most 
prominent  point  of  the  parietal  eminence. 

If  clot  is  not  found  on  removal  of  the  bone,  some  blunt  instrument 
should  be  passed  from  the  opening  in  ai^  directions,  and  especially  toward 
the  base,  in  order  to  endeavor  to  tap  the  clot. 

One  often  sees  patients,  profoundly  unconscious  and  not  moving  any 
limb,  after  a  head  injury,  and  regarding  whom  no  history  maybe  forth- 
coming. Percussion  of  the  skull  is  a  help  in  these  cases,  and  if  a  hollow 
or  a  cracked-pot  note  is  obtained  in  the  temporal  region  in  such  an 
individual,  or,  if  a  hematoma  be  present  in  the  temporal  region,  the 
writer  is  strongly  of  opinion  that  the  skull  should  be  explored. 

There  are  some  cases  in  which  it  may  be  necessary  to  trephine  at 
several  points  to  thoroughly  evacuate  an  extradural  hematoma. 

Hemorrhage  from  the  venous  sinuses  of  the  dura  mater  is  much 
less  frequent  than  from  the  middle  meningeal  artery  although  produced 
in  much  the  same  manner.  In  addition  to  lacerations  by  fractures  of 
the  bones,  or  to  penetration  by  sharp  weapons,  a  sinus  may  be  torn, 
owing  to  the  change  of  shape  of  the  skull  as  the  result  of  the  \'iolence. 
There  are  several  well-authenticated  cases  where  a  dural  blood  sinus  was 
found  ruptured  in  the  absence  of  a  fracture. 

As  in  the  case  of  bleeding  from  the  meningeal  artery,  the  hemorrhage 
may  be  inside  or  outside  the  dura  or  in  both  situations  in  the  same 
patient.     A  fracture  of  the  bone  over  the  torn  sinus  may  permit  blood 


50  REGIONAL   SURGERY 

to  escape  and  form  a  hematoma  beneath  the  scalp ;  while  in  some  cases  a 
depressed  fracture  may  so  compress  the  torn  vessel  that  no  bleeding 
occurs  from  it  until  the  fragments  are  elevated  at  an  operation.  The 
superior  longitudinal  sinus  and  the  lateral  sinus  have  both  been  torn 
from  deformation  of  the  foetal  skull  during  labor. 

The  relative  frequency  of  hemorrhage  from  the  sinuses  is  rather 
difficult  to  estimate.  Chipault  in  117  cases  of  intracranial  hemorrhage 
found  72  were  from  the  meningeal  artery  and  30  from  the  sinuses, 
whereas  Phelps  in  300  cases  of  head  injury  found  only  4  cases  of  sinus 
bleeding. 

The  longitudinal  sinus  was  injured  in  40  cases  out  of  76  collected  by 
Wharton,  the  lateral  in  26,  and  the  cavernous  in  3. 

Extradural  hemorrhage  from  one  of  these  sinuses  is  not  extensive,  as 
a  rule,  unless  the  blood  can  escape  from  the  skull,  for  the  blood  pressure 
is  low,  and  wide  stripping  of  the  dura  from  the  bone  does  not  take  place 
easily. 

In  open  injuries  to  the  sinuses  air  may  be  aspirated  into  the  lumen  of 
the  vessel,  and  the  accident  has  been  followed  by  death. 

There  are  some  cases  in  which  a  differential  diagnosis  between  hem- 
orrhage from  a  sinus  or  a  meningeal  artery  cannot  be  established  before 
operation.  The  discovery  of  a  fracture  over  the  site  of  one  of  the 
sinuses  may  lead  one  to  suspect  the  possibility  of  injury  to  it. 

Where  hemorrhage  takes  place  into  the  subdural  space,  signs  of 
general  compression  usually  develop  rapidly,  although  in  a  certain 
number  of  cases  convulsions,  at  times  general,  at  others  strictly 
localized  in  their  origin  and  sequence,  are  seen.  On  the  other  hand, 
even  with  an  intradural  hemorrhage  from  this  source,  strictly  localized 
paralysis  (hemiplegia)  has  been  observed;  and  there  may  be  a  lucid 
interval;  Luys  found  that  it  was  present  in  67  out  of  127  cases  collected 
by  him. 

Prognosis. — The  condition  is  not  a  slight  one.  Wharton  found 
recovery  occurred  in  only  25  out  of  70,  and  Luys  in  14  out  of  36  cases. 
If  the  primary  dangers,  death  from  hemorrhage  (when  the  wound  of  the 
sinus  is  an  "open"  one),  or  from  compression  of  the  brain  are  survived, 
septic  thrombosis  constitutes  the  most  serious  complication,  with  the 
possibility  of  pyemia,  infective  meningitis,  or  abscess  of  the  brain  as  a 
result. 

Treatment  is  to  be  directed  toward  the  arrest  of  hemorrhage  and  the 
relief  of  pressure  symptoms  when  they  are  present.  For  the  actual 
arrest  of  the  hemorrhage  suture  of  the  wound  in  the  sinus  has  been  sue- 


TRAUMATA   OF    THE    SKULL   AND   CONTENTS  5 1 

cessful  and,  if  feasible,  is  the  ideal  method  to  employ,  but  the  tension 
of  the  walls  of  the  sinus  may  be  so  great  as  to  render  it  difficult.  Liga- 
tion has  been  tried,  and  proved  satisfactory  in  some  cases,  but  it,  too,  may 
not  be  easy,  and  the  attempt  to  do  so  may  lead  to  injury  of  the  brain,  or 
of  the  pial  vessels.  Packing  is  sometimes  efl&cacious;  strips  of  gauze 
may  be  introduced  between  the  bone  and  the  sinus  wall,  or  into  the 
opening  in  the  sinus  itself  and,  if  asepsis  can  be  maintained,  will  allow 
clotting  to  go  on  satisfactorily. 

Under  the  term  "sinus  pericranii"  Stromeyer  described  a  condition 
which  results  from  trauma  and  in  which  there  is  formed  a  tumor  con- 
taining blood  and  placed  beneath  the  pericranium,  communicating  with 
a  sinus  of  the  dura  or  of  the  diploe.  It  is  practically  a  venous  aneurism; 
it  pulsates,  enlarges  during  straining  efforts,  and  may  be  more  or  less 
reducible  by  pressure  over  its  surface.  One  such  case  at  least  has  been 
cured  by  excision. 

Cerebral  Laceration  and  Injury  to  the  Vessels  of  the  Pia  Mater. — 
While  laceration  of  the  substance  of  the  brain  may  be  central  or  cortical, 
the  latter  is  much  more  often  seen  and  is  practically  always  associated 
with  more  or  less  extensive  injury  to  the  vessels  of  the  pia  mater. 

Laceration  of  the  brain  is  brought  about  directly,  e.g.,  by  depressed 
fragments  of  bone;  or  indirectly  in  consequence  of  (i)  the  change  of 
shape  of  the  skull  and  brain,  the  result  of  the  violence,  or  (2)  contre-coup 
(the  brain  being  injured  at  the  pole  opposite  to  that  which  receives  the 
brunt  of  the  force)  and,  as  such,  is  seen  especially  often  at  the  poles  of 
the  frontal  and  temporo-sphenoidal  lobes.  Laceration  by  contre-coup 
is  often  extreme,  whereas  that  due  to  direct  injury  is  often  compara- 
tively slight. 

That  laceration  of  the  brain  can  be  caused  by  temporary  deformation 
of  the  brain  seems  to  be  undoubted.  The  "bursts "  of  the  surface  of  the 
brain  s?en  in  the  case  of  children — "bursts"  which  may  extend  from  the 
cortex  into  one  of  the  lateral  ventricles — are  certainly  produced  in  this 
manner,  and  the  lacerations  of  the  substance  of  the  white  matter  of  the 
cerebrum,  pons  or  cerebellum  which  may  occur  without  any  macro- 
scopic evidence  of  injury  to  the  cortex  must  arise  from  this  cause. 
These  central  lacerations  may  lead  to  great  efifusions  of  blood  which  at 
times  can  reach  the  ventricles  and  escape  thence  into  the  subarachnoid 
space — effusions  so  great  that  death  takes  place  rapidly  from  com- 
pression of  the  brain.  On  the  other  hand,  they  may  be  small  in  extent 
and  ultimately  undergo  absorption. 

Cortical  lacerations  when  extensive  are  generally  the  result  of  a 


52  REGIOXAL   SURGERY 

contre-coup,  the  brain  impinging  against  the  internal  ^Yall  of  the  skull. 
The  writer  believes  that  the  theory  of  a  separation,  a  tearing,  which 
takes  place  between  the  gray  and  the  white  matter  of  the  cortex  in  con- 
sequence of  a  difference  in  their  specific  weights  explains  some  of  these 
cases;  for  lacerations  are  seen  where  contre-coup  does  not  explain  their 
presence,  and  in  the  immediate  proximity  to  almost  every  laceration  one 
can  see  minute  hemorrhages  between  the  gray  and  white  matter  for 
some  distance. 

With  the  laceration  of  the  brain  cortex,  rupture  of  some  pial  vessels 
takes  place  and  hemorrhage  ensues.  In  a  considerable  number  of 
.  cases  rupture  of  these  vessels  occurs  over  a  large  area  and  often  with 
strictly  localized  laceration  of  the  brain  at  one  or  two  points  only;  these 
cases  of  pial  hemorrhage  are  certainly  the  result  of  the  shakings  and 
deformation  of  the  brain.  The  hemorrhage  in  these  latter  cases  is  often 
diffused  over  the  whole  surface  without  rupture  of  the  overlying  arach- 
noid so  that  the  blood  forms  a  thinly  spread-out  layer  over  the  convolu- 
tions, filling  the  sulci  and  producing  an  appearance  that  is  quite  char- 
acteristic and  one  that  is  only  simulated  in  anthracaemia;  in  the  latter 
case,  however,  the  evidence  of  laceration  of  the  brain  is  wanting  and  the 
bacillus  is  to  be  found  in  the  blood. 

In  other  traumatic  cases  the  arachnoid  is  ruptured;  the  blood 
escapes  from  below  it  into  the  subdural  space,  and  extensive  subdural 
hematomata  may  form,  the  blood  tending  to  gravitate  into  the  middle 
and  posterior  fossae  of  the  skull  and  down  into  the  spinal  canal. 

In  cases  of  diffused  hemorrhage  arising  in  this  manner  patients  pass 
rapidly  into  the  state  of  compression  of  the  brain  which  will  progress  to 
a  fatal  termination,  unless  operation  can  give  relief.  The  majority  of 
patients  suft'ering  from  this  condition  are  in  such  a  serious  state  when 
they  come  under  the  observation  of  a  surgeon  that  the  question  of  an 
operation  is  hopeless.  If  there  be  any  chance  of  being  able  to  complete 
an  operation,  the  writer  is  strongly  of  the  opinion  that  it  ought  to  be 
carried  out:  although  the  greater  number  of  patients  still  die  in  spite  of 
it,  it  will  occasionally  happen  that  a  life  is  prolonged. 

The  Circumscribed  Subdural  Hemorrhage  is  invariably,  one  may  say, 
associated  with  localized  cerebral  laceration,  the  violence  at  the  same 
time  causing  rupture  of  some  of  the  pia-arachnoid  vessels. 

The  frequency  with  which  these  lacerations  occur  upon  the  inferior 
surface  of  the  frontal  lobes  and  at  the  anterior  pole  of  the  temporo-sphe- 
noidal  lobes  has  been  alluded  to,  but  any  portion  of  the  brain's  surface 
may  be  affected.     They  occur  upon  the  mesial  aspect  of  the  cerebral 


TRAUMATA   OF   THE    SKULL   AXD    CONTENTS  53 

hemisphere  as  well  as  upon  the  convexity :  some  of  these  cases  are  the 
result  or  the  impact  of  the  brain  against  the  falx  cerebri;  others  are 
tears  due  to  deformation  of  the  brain  at  the  moment  of  impact  of  the 
violence. 

To  the  naked  eye  a  recent  laceration  shows  an  appearance  not  inaptly 
compared  to  that  of  black  currant  jelly.  The  disintegrated  tissue 
mingled  with  blood-clot  may  undergo  a  gradual  absorption  and  ulti- 
mately result  in  a  cicatrix  which  may  be  soHd  but  is  often  cystic;  at  one 
time  a  single  cyst  is  formed,  but  at  others  numerous  small  cysts  are 
developed,  and  a  spongy  cicatrix  is  the  result.  The  fluid  contained  in 
such  cysts  may  be  clear  but  is  often  tinged  with  the  disintegration  prod- 
ucts of  blood  coloring  matter.  The  cicatrices  themselves  contain 
cholesterin  and  remain  pigmented  for  years.  Until  cicatrization  is 
complete  there  is  always  the  possibility  of  hemorrhage  occurring  from 
the  granulations  and  the  development  of  the  so-called  "traumatic  late 
apoplexy."  In  a  certain  number  of  cases  of  cerebral  laceration  a 
spreading  oedema  of  the  soft  membranes  and  underlying  brain  may 
develop,  leading  to  a  severe  and  fatal  compression  of  the  brain. 

Infection  of  the  injured  area  may  be  set  up  at  any  time;  directly 
when  wounds  of  the  scalp  and  bone  exist,  or  indirectly  (though  more 
rarely)  through  the  medium  of  the  blood  stream,  and  so  an  encephalitis 
or  a  meningitis  can  be  established. 

The  symptoms  which  follow  in  these  injuries  are  very  varied  and  are 
dependent  upon  the  area  of  the  brain  involved  and  the  amount  of  hemor- 
rhage associated  with  the  injury.  Where  the  hemorrhage  is  excessive 
and  diffused,  general  symptoms  of  compression  are  rapidly  established. 
Even  in  the  slight  degrees  of  laceration  patients  are  thrown  at  the 
moment  into  a  state  of  unconsciousness  due  to  concussion,  from  which 
they  generally  recover,  though  not  completely. 

In  one  type  of  the  condition  which  is  fairly  characteristic  and 
generally  associated  with  superficial  lacerations  of  the  frontal  and  tem- 
poral lobes  the  patient  lies  in  a  state  of  general  flexion  which  is  at  once 
resumed  should  any  attempt  be  made  to  extend  the  limbs;  while  the 
head  is  often  kept  buried  in  the  pillow  or  bedclothes.  The  patient 
takes  no  notice  of  his  surroundings,  often  moans,  and  when  disturbed 
resists,  grinds  the  teeth,  and,  if  sufficiently  educated,  often  swears. 
There  is  resistance  to  attempts  at  opening  the  eyelids,  which  are  always 
firmly  closed,  but  when  the  pupils  can  be  seen  in  this  stage,  they  are  of 
medium  size  and  react  to  light.  Swallowing  is  not  interfered  with. 
Urine  and  faeces  are  frequently  passed  involuntarily.     The  temperature 


54  REGIONAL   SURGERY 

in  the  early  stage  is  subnormal  but  after  24  hours  is  always  ele- 
vated. In  the  early  stage  the  patient  lies  quietly  but,  as  the  condition 
passes  off,  becomes  restless,  and  headache  is  complained  of,  generally  in 
the  frontal  region.  This  condition  constitutes  what  is  known  as  "  Cere- 
bral Irritation."  If  the  laceration  is  in  the  Rolandic  area,  Jacksonian 
convulsive  seizures  may  be  met  with,  but  frequently  a  monoplegia  or,  in 
other  instances,  a  weakness  or  a  paralysis  of  both  limbs  on  the  side 
opposite  to  the  damaged  area  will  be  seen.  The  facial  muscles  are 
involved  in  some  cases,  and  if  Broca's  convolution  should  be  implicated 
there  will  be  motor  aphasia. 

A  lesion  at  the  angular  gyrus  has  been  known  to  produce  word- 
blindness;  one  involving  the  superior  temporo-sphenoidal  convolution 
will  bring  about  a  state  of  word-deafness,  and  one  implicating  the  occi- 
pital lobe,  especially  if  near  the  parieto-occipital  fissure,  will  cause  a 
hemianopia. 

Patients  who  suffer  from  laceration  occasionally  develop  signs  of 
compression,  the  result  of  an  oedema  of  the  soft  membranes  and  of  the 
brain,  comparatively  localized  in  some  cases  and  general  in  others,  and 
not  a  few  deaths  result  from  this  cause.  With  this  oedema  it  is  not 
uncommon  in  the  writer's  experience  to  see  evidence  of  transient  and 
evanescent  paralysis  of  one  or  other  of  the  cranial  nerves  (the  3rd  or  6th 
being  most  often  affected)  due  probably  to  effusion  into  or  around  the 
nerve  sheaths. 

A  degree  of  choked  disc  will  very  constantly  be  found  to  be  present 
if  looked  for. 

The  temperature  is  very  generally  elevated  at  some  stage.  Subnor- 
mal to  begin  with,  if  the  patient  does  not  die  in  the  early  period, 
it  will  rise;  it  may  do  so  rapidly  and  reach  a  state  of  hyperpyrexia 
within  a  few  hours  and  almost  every  patient  in  whom  this  happens 
will  die.  The  temperature  rises  in  some  cases  to  io2°F.  or  there- 
abouts, remains  at  that  level  for  a  varying  period,  to  fall  in  the 
cases  which  recover,  bat  rising  in  others  and  then  usually  ending  in  death. 

When  hemorrhage  occurs  from  lacerations  at  the  base  of  the  brain  or 
gravitates  into  the  posterior  fossae,  it  is  very  usual  to  find  an  extreme 
degree  of  rigidity  of  the  patient's  neck  and  a  difficulty  in  swallowing, 
both  symptoms  due  to  interference  with  the  last  cranial  nerves  (loth, 
nth  and  12th)  and  the  higher  cervica;!  nerves  by  the  blood  and  serum 
exuded. 

It  is  these  lacerations  of  the  brain  that  give  rise  to  the  so- 
called  "  traumatic  late  apoplexy."     Under  this  term  Bollinger  described 


TRAUMATA    OF   THE    SKULL   AND   CONTENTS  55 

cases  of  what  is  really  a  secondary  hemorrhage  taking  place  as  the 
result  of  softening  and  necrosis  of  brain  tissue  following  contusions  and 
lacerations. 

Such  hemorrhages  may  come  on  days  or  weeks  after  the  primary 
injury,  from  which  the  patient  may  have  recovered  to  a  certain  extent 
though  not  completely;  he  may  be  suffering  from  a  slight  degree  of  cere- 
bral irritation,  headaches,  disturbed  sleep  and  more  or  less  mental  irri- 
tability. These  signs  are  present  over  a  varying  period  in  a  large  num- 
ber of  cases  of  cerebral  contusion  that  gradually  recover,  but  in  that 
class  of  patients  who  ultimately  develop  symptoms  of  the  traumatic  late 
apoplexy  (viz.:  paresis  developing  into  localized  paralysis,  with  or 
without  epileptiform  seizures,  indications,  that  is,  of  localized  pressure) 
they  are  spoken  of  as  constituting  the  "latent"  period. 

The  treatment  of  circumscribed  subdural  hematomata  must  be 
by  operation.  When  the  area  of  brain  that  is  injured  is  extensive,  the 
hemorrhage  in  the  early  stage  can  be  sufficient  to  produce  a  condition  of 
general  compression.  The  site  for  operation  is  to  be  decided  upon  by 
a  consideration  of  the  nature  of  the  accident  as  far  as  is  known,  of  the 
evidence  of  bruising  of  the  scalp,  and  the  results  of  percussion  of  the 
skull  for  the  determination  of  a  possible  fracture.  Contusions  and 
hemorrhages  are  very  constantly  at  the  opposite  pole  of  the  skull  from 
that  assaulted  and  it  is  frequently  necessary  to  operate  at  both  poles. 

Blood  and  brain  debris  must  be  gently  removed,  the  cavity  ex- 
plored as  to  its  extent,  and  very  often  secondary  openings  require  to 
be  made  in  the  bone  to  permit  thorough  evacuation  and  drainage. 
Where  localizing  symptoms  are  present  they  point  to  the  situation  at 
which  the  skull  is  to  be  opened. 

There  is  still  a  large  group  of  cases  in  which  operation  may  not  be 
required  until  symptoms  of  distinct  compression  arise.  The  causes  of 
this  compression  are  either  oedema  of  the  soft  membranes,  further 
hemorrhage  (traumatic  late  apoplexy),  or  infections  (meningitis  or 
abscess  formation) .  The  writer  believes  that  free  purgation  by  sulphate 
of  magnesia  is  of  great  service  in  many  cases  where  a  compression 
operation  is  not  indicated,  by  tending  to  lower  blood  pressure,  and 
that  venesection  also  has  value. 

Lumbar  puncture  has  been  advocated  as  a  means  of  diminishing 
intracranial  tension  but  in  the  writer's  experience  does  not  appear  to 
have  any  great  effect. 

Every  patient  who  suffers  from  contusion  or  laceration  of  the  brain 
ought  to  be  kept  at  most  complete  rest  and  quiet,  by  preference  in  a 


56  REGIONAL    SURGERY 

darkened  room,  and  at  least  until  every  trace  of  mental  irritability, 
headache,  etc.,  has  passed  off.  The  writer  is  unable  to  appreciate  the 
supposed  benefit  of  giving  these  patients  early  "mental  exercise,"  as 
has  been  recently  advocated. 

The  patients  who  suffer  from  cerebral  irritation  require  to  be  kept 
quiet.  If  marked  restlessness  shows,  bromides  or  opium  will  prove 
useful. 

In  connection  with  the  subject  of  Subdural  Hemorrhage  mention 
requires  to  be  made  of  the  hemorrhages  which  take  place  over  the 
foetal  brain  during  labor.  During  long  and  difficult  labor,  which  may 
or  may  not  be  instrumental,  hemorrhages  occur  in  certain  cases. 
They  may  be  over  the  vertex  of  the  brain  or  at  the  base:  in  the  latter 
case  they  are  frequently  in  the  posterior  fossa  and  generally  prove 
fatal.  The  hemorrhage  is  usually  subdural  but  may  be  confinedi  to  the 
meshes  of  the  pia  mater.  It  occurs  very  generally  over  the  Rolandic 
region  when  at  the  vertex,  and  is  often  bilateral.  The  hemorrhage  is 
probably  greatest,  i.e.,  the  clot  is  thickest,  near  the  superior  longi- 
tudinal sinus,  and  may  extend  down  the  mesial  surface  of  the  hemi- 
sphere. As  a  result,  when  the  child  survives,  spastic  paraplegia  is 
developed  affecting  one  or  both  sides  of  the  body  (Little's  Disease)  and, 
not  infrequently,  is  associated  with  epilepsies  of  the  Jacksonian  type. 
If  the  hemorrhage  extends  beyond  the  Rolandic  convolutions  the 
mental  powers  of  the  child  may  be  seriously  interfered  with. 

There  is  little  doubt  that  the  prolonged  labor,  and  the  resulting 
compression  of  the  head  and  asphyxia,  are  the  active  causes  of  these 
hemorrhages,  but  it  is  remarkable  that  so  many  of  these  infants  give  a 
positive  Wassermann  reaction. 

After  a  long  labor,  a  child  the  subject  of  a  hemorrhage  of  this 
nature  shows  evidences  of  intracranial  pressure.  The  fontanelle  bulges, 
the  scalp  veins  are  unduly  prominent,  the  infant  may  be  difficult  to 
rouse.  More  localizing  signs  are  found  in  inability  to  move  one  or 
more  of  the  limbs,  or  in  twitchings  or  rigidity  or  actual  convulsive 
seizures. 

A  lumbar  puncture  will,  in  the  case  of  blood  escaping  into  the  sub- 
dural space,  be  of  help  as  a  diagnostic  point,  but  where  the  hemorrhage 
is  confined  by  the  pia  mater,  blood  is  not  found  in  the  cerebro-spinal 
fluid. 

The  patients  with  basal  hemorrhages  die  early.  Swallowing  may 
be  a  difficulty  in  these  cases. 

Treatment  to  be  effective  must  be  by  means  of  operation,  and  if  this 


TRAUMATA   OF   THE    SKULL   AND    CONTENTS  57 

is  to  be  useful  it  must  be  carried  out  early,  while  there  is  a  possibility 
of  being  able  to  remove  the  clot,  within  the  first  two  weeks;  otherwise 
it  will  be  anchored  to  the  brain  and  pia  mater  by  granulation  tissue 
penetrating  it  in  the  process  of  absorption. 

Pulsating  exophthalmos  is  a  somewhat  rare  condition  seen  after 
traumata  of  the  skull,  as  the  result  of  which  there  is  brought  about  a 
communication  between  the  internal  carotid  artery  and  the  cavernous 
sinus.  The  affection  may  result  from  direct  injury  to  the  vessels  by 
objects  penetrating  through  the  orbit,  or  indirectly  from  violence 
applied  at  a  distance. 

Signs  of  the  lesion  are  not  usually  evident  immediately  after  the 
injury,  being  masked  by  the  symptoms  of  the  head  lesions,  but  they  are 
generally  fully  developed  within  nine  months  of  the  accident,  and 
frequently  within  two.  The  typical  symptoms  are  exophthalmos, 
pulsation  of  the  eyeball,  bruit,  and  noises  in  the  head,  distention  of 
conjunctival  vessels,  paralysis  of  extrinsic  ocular  muscles,  and  of  the 
iris,  with  or  without  anaesthesia.  Vision  may  be  greatly  diminished 
or  lost  altogether,  and  in  the  early  stages  there  may  be  a  choked  disc 
which  may  run  on  into  atrophy. 

While  spontaneous  retrocession  and  cure  of  the  tumor  has  been 
known  to  take  place,  it  is  extremely  rare. 

Treatment  by  ligation  of  the  common  carotid  artery  has  given 
very  favorable  results. 

WOUNDS  OF  THE  BRAIN 

"Wounds  of  the  Brain. — Wounds  of  the  brain  are  only  seen  as  com 
plications  of  injury  to  the  skull  itself,  except  in  the  rare  instances  in 
which  penetration  of  the  cranial  cavity  takes  place  directly  through 
the  orbit  and  orbital  fissure  by  pointed  objects  without  a  fracture 
being  associated  therewith.  Apart  from  these  uncommon  injuries, 
wounds  of  the  brain  are  met  with  as  the  result  of  depressed  fractures, 
or  are  the  consequence  of  sword,  hatchet,  bullet  or  circular  saw  injuries. 

These  injuries  to  the  brain  are  of  much  importance,  for  practically 
every  wound  of  the  brain  is  a  contused  wound,  and  every  wound  not 
made  by  a  surgeon  is  an  infected  wound;  it  is  infection  that  gives  the 
importance  to  the  type  of  injury  under  consideration. 

Daggers  and  other  objects  which  produce  penetrating  wounds  may 
be  broken  off  and  part  of  the  blade  be  left  in  the  cranial  cavity,  or  the 
ferrule  of  a  walking  stick  may  remain  inside  the  skull.     Such  foreign 


58  REGIONAL  SURGERY 

bodies  may  give  no  trouble  at  the  time  of  the  injury  but  around  them 
an  abscess  may  ultimately  develop.  The  wound  inflicted  by  a  hatchet 
or  sword,  by  which  a  slice  of  the  skull  wall  is  elevated  or  cut  clean  away 
and  the  membranes,  brain,  etc.,  beneath,  variously  injured  but  always 
in  part  crushed,  is  perhaps  less  dangerous  than  many  others,  for  with  a 
large  opening  in  the  bone  there  is  a  free  vent  for  drainage,  and  tension 
need  not  arise  within  the  skull. 

The  treatment  as  far  as  the  actual  injury  to  the  brain  is  concerned 
is  to  be  directed  to  the  removal  of  foreign  bodies,  hair,  dirt  of  all  kinds, 
portions  of  the  injuring  weapon,  etc.  Bruised  particles  of  the  brain 
are  to  be  gently  washed  away  and  provision  made  for  drainage.  The 
wound  in  the  soft  parts  should  be  left  open  until  asepsis  is  assured. 
The  question  of  attempting  to  close  the  opening  in  the  skull  may 
eventually  have  to  be  considered. 

Hernia  of  the  Brain. — As  met  with  after  traumatism,  a  cerebral 
hernia  is  always  associated  with  the  presence  of  sepsis  in  consequence 
of  which  a  mass  of  granulation  tissue,  derived  from  the  brain,  protrudes 
through  an  opening  in  the  membranes,  skull  and  scalp.  It  appears  as 
a  red  mushroom-shaped  tumor  showing  here  and  there  signs  of  localized 
necrosis  or  hemorrhage,  with  patches  of  a  yellow-white  fibrinous  exuda- 
tion at  its  surface.  The  tumor  may  or  may  not  pulsate,  it  often  be- 
comes tenser  during  forced  expiratory  efforts  of  the  patient. 

A  puriform  leptomeningitis  is  not  infrequently  established  with 
death  as  the  ultimate  outcome.  But,  in  cases  where  the  virulence  of 
the  infecting  organism  is  not  great,  a  sealing  off  of  the  arachnoid  space 
can  take  place  in  consequence  of  which  the  infective  process  remains 
locaHzed.  Such  cases  may  terminate  in  recovery  if  the  sepsis  can  be 
overcome;  it  may  be  only  after  gangrene  of  considerable  masses  of  the 
granulation  tissue  forming  the  tumor,  during  which  process  there  is  a 
risk  that  the  cavity  of  the  lateral  ventricle  may  be  opened  into  and  a 
general  leptomeningitis  be  established;  but  if  this  accident  does  not 
occur  the  tumor  shrinks  to  the  level  of  the  skull  and  will  cicatrize  over. 
There  is  always  the  possibility,  however,  of  serious  psychical  changes 
developing  in  such  cases. 

Treatment  must  be  preventive,  and  cerebral  hernia  is  now-a-days 
a  condition  only  rarely  met  with.  When  a  hernia  is  developing,  free 
removal  of  the  bone  around,  without  any  interference  whatever  with 
the  membranes,  and  the  employment  of  aseptic  dressings  is  probably 
the  best  Une  to  pursue  until  such  time  as  recession  and  shrinkage  of  the 
tumor  shall  have  taken  place. 


TRAUMATA  OF   THE   SKULL  AND   CONTENTS  59 

The  Intracranial  Infections. — Infective  organisms  may  be  directly 
implanted,  carried  straight  to  the  site  of  their  action,  as  the  result  of 
penetrating  wounds  of  the  vault  or  the  base  of  the  skull;  or  may  reach 
the  interior  of  the  skull  secondarily,  by  continuity  of  tissue  through 
open  fractures;  or,  arising  in  a  septic  abrasion  of  the  scalp  or  an  infective 
osteitis,  without  any  fracture,  and  spreading  along  thrombosed  vessels, 
may  lead  to  a  meningitis,  abscess  of  the  brain,  or,  less  frequently,  to  a 
sinus  phlebitis. 

But,  on  the  other  hand,  given  a  zone  of  contused  brain  tissue — an 
extravasation  of  blood  beneath  the  arachnoid  or  outside  the  dura  mater 
— infection  may  reach  the  dead  tissue,  clot,  etc.,  by  the  blood  stream 
from  some  distant  focus  in  the  body. 

The  causal  agents  of  the  infection  in  these  cases  may  be  any  of  the 
ordinary  pus-producing  organisms.  When  the  infection  arises  from 
the  nasopharynx  or  middle  ear,  as  is  not  infrequently  the  case  in  basal 
fractures,  the  pneumococcus  is  generally  at  fault. 

A  meningitis  may  be  limited  to  the  dura  mater  (pachymeningitis), 
in  which  case  it  is  generally  localized  to  form  an  extradural  abscess,  but 
an  abscess  may  form  between  the  dura  and  the  brain,  the  general  sub- 
dural space  being  closed  off  by  adhesions  between  the  arachnoid  and 
the  dura.  If  infection  spreads  through  the  dura  mater,  whether  owing 
to  the  latter's  having  been  lacerated  at  the  accident  or  from  mere  con- 
tinuity of  tissue,  it  is  more  usual  for  a  diffuse  leptomeningitis  to  be 
established. 

Symptoms  of  meningitis  following  upon  trauma  may  develop  within 
three  days  of  the  injury  or  may  be  delayed  for  three  weeks  or  longer; 
the  more  directly  the  infection  occurs,  the  more  rapid  is  the  develop- 
ment of  symptoms.  These  manifest  themselves  by  the  onset  of  head- 
ache, restlessness,  a  sudden  rise  of  temperature  to  io3°F.-io5°F.,  quick 
pulse  (the  pulse  of  septic  intoxication  and  not  of  compression,  although 
there  is  increased  intracranial  tension),  rapid  respiration,  weakness, 
often  marked  rigidity,  of  the  limbs  which  occasionally  develops  into  a 
complete  paralysis;  at  times  there  are  convulsive  seizures.  Vomiting  is 
uncommon,  and  a  rigor  is  on  the  whole  rare.  In  basal  meningitis 
ocular  palsies  or  interference  with  one  of  the  facial  nerves  may  be  met 
with;  and  when  the  infective  process  reaches  the  posterior  fossa  and  the 
membranes  over  the  medulla  and  upper  cervical  cord,  there  is  difficulty 
in  swallowing  and  rigidity  of  the  neck  muscles. 

The  pupils  are  often  unequal,  and  as  the  tension  increases  witliin 
the  skull  they  dilate.     A  choked  disc  will  often  be  found  if  looked  for. 


6o  REGIONAL   SURGERY 

The  bowels  are  generally  constipated;  the  urine  is  often  passed  in- 
voluntarily. By  lumbar  puncture  turbid  fluid  due  to  the  presence  of 
leucocytes  and  organisms  is  obtained. 

In  those  cases  where  an  extra  or  subdural  abscess  develops  in  the 
absence  of  a  wound  of  the  scalp  of  greater  extent  than  an  abrasion,  it 
will  often  be  found  that  a  zone  of  oedema  of  the  scalp  forms  in  the 
immediate  neighborhood  of  the  pus.  It  is  never  a  large  swelling  and 
can  readily  be  overlooked.  It  is  known  as  Pott's  "puffy  tumor," 
after  Percival  Pott  who  first  drew  attention  to  it.  It  is  a  sign  of  conse- 
quence, for  in  the  absence  of  definite  localizing  signs,  such  as  paralysis 
of  a  defined  group  of  muscles-  or  convulsive  seizures,  its  presence  indi- 
cates one  spot  for  exposing  the  bone,  and  in  most  cases  for  a  trephine 
opening  to  be  made. 

Thrombosis  of  the  Sinuses  of  the  Dura  Mater. — Sinus  thrombosis 
is  generally  seen  as  a  complication  of  septic  wounds  of  the  scalp  or 
skull,  thrombosis  of  some  tributary  vein  occurring  in  the  first  place  and 
spreading  to  the  larger  vessel.  But  in  rare  cases  it  is  seen  as  a  com- 
plication of  a  meningitis. 

The  clot  frequently  disintegrates  and,  especially  in  the  case  of  the 
lateral  sinus,  leads  to  pyaemia,  secondary  metastatic  abscesses  forming 
in  the  lungs  particularly,  and  immediately  under  the  pleural  coverings. 

The  superior  longitudinal  sinus  is  specially  prone  to  be  involved  in 
fractures  of  the  vault;  the  lateral  sinuses  in  fractures  of  the  posterior 
fossa,  particularly  those  traversing  the  tympanum  or  mastoid  process, 
and  the  cavernous  sinus  in  fractures  of  the  base  of  the  middle  fossa. 

The  signs  of  involvement  of  the  cavernous  sinus  are  fairly  charac- 
teristic, the  most  obvious  being  the  protrusion  of  the  eyeball  and 
oedema  of  the  eyelids,  sometimes  also  of  the  conjunctiva,  with  paralysis 
of  one  or  more,  or  all,  of  the  ocular  muscles  of  the  same  side,  a  fixed 
dilated  pupil  and  the  existence  of  a  choked  disc. 

With  thrombosis  of  the  superior  longitudinal  sinus  epistaxis  is  said 
to  be  common,  and  the  veins  of  the  scalp  are  prominent. 

Thrombosis  of  the  lateral  sinus,  and  especially  after  the  sigmoid  and 
the  bulb  of  the  jugular  vein  have  been  affected,  may  lead  to  an  oedema 
over,  or  just  below,  the  mastoid  process;  and  if  the  thrombus  extends 
along  the  jugular  vein  one  can  feel  a  thickened,  cord-like  mass  along 
the  course  of  the  vessel  in  the  neck. 

In  all  cases  pain  in  the  head  is  present,  and  vomiting  may  occur 
ea-rly.  With  disintegration  of  the  clot  and  the  dissemination  of  emboli 
there  is  a  lighting  up  of  marked  symptoms.     Very  generally  a  rigor 


TRAUMATA   OF   THE    SKULL   AND    CONTENTS  6 1 

leads  off,  to  be  repeated  at  intervals,  with  rise  of  temperature  which 
fluctuates  within  wide  limits  during  the  course  of  the  disease.  The 
pulse  is  rapid  and  small.  The  tongue  becomes  dry  and  brown;  sordes 
develop  on  the  teeth.  The  lungs  are  often  involved;  patients  complain 
of  pain  in  the  chest,  develop  a  cough  with  a  dirty  prune-colored  and 
often  very  foul  expectoration.  The  physical  signs  of  pleurisy  may  be 
present;  occasionally  one  of  the  abscesses  bursts  into  the  pleural  cavity 
and  a  diffuse  effusion  is  established. 

In  other  cases  there  is  an  inveterate  diarrhoea  with  offensive  stools, 
not  unlike  what  is  seen  in  enteric  fever. 

If  a  meningitis  is  not  set  up  secondarily,  it  is  remarkable  how  long 
these  patients  may  go  without  loss  of  consciousness,  and  how  long  they 
live  even  when  the  case  is  going  on  to  a  fatal  termination. 

Encephalitis  and  Cerebral  Abscess. — EncephaHtis  can  seldom  be 
distinguished  from  meningitis  (the  two  being  almost  invariably  as- 
sociated) in  traumatic  cases. 

Cerebral  abscess  following  upon  trauma  may  be  acute  or  chronic. 
The  former  arises  from  infection  reaching  an  area  of  brain  tissue  in  a 
state  of  red  softening. 

The  chronic  abscess  may  exist  for  long  periods  but  at  any  time 
may  be  lighted  up  to  fresh  activity.  The  brain  surrounding  these 
abscesses  is  practically  normal  in  appearance. 

The  traumatic  cerebral  abscess  is  generally  the  result  of  injury  to 
the  vertex  of  the  cerebrum  and  is  usually  seated  in  either  the  frontal  or 
the  parietal  lobe. 

The  early  symptoms  are  indefinite,  but  pain  in  the  head  is.  present 
in  most  cases  from  an  early  stage.  A  rigor  or  series  of  rigors  may 
herald  the  more  obvious  cerebral  symptoms  of  vomiting,  drowsiness 
and  slow  mental  efforts.  The  pulse,  respiration  and  temperature,  in 
the  early  stage,  may  be  elevated,  but  later  the  temperature  falls  and 
the  pulse  and  respiration  become  slowed. 

Paralysis  (mono-  or  hemiplegia,  or  facial  in  its  type)  may  manifest 
itself  along  with  dilated  pupils  and  choked  discs.  Emaciation  is  a 
pronounced  feature  in  the  chronic  abscess  cases  particularly.  Evidence 
of  Pott's  puffy  tumor  should  be  looked  for  in  traumatic  cases.  Infec- 
tion is  generally  in  the  neighborhood  of  the  direct  injury  but  may  be  at 
a  part  injured  by  contre-coup. 

The  treatment  of  these  infective  complications  of  traumatism  must, 
in  the  first  place,  be  preventive  by  the  most  scrupulous  asepsis  of  all 
wounds  of  the  scalp  and  of  the  bone. 


62  REGIONAL   SURGERY 

Wounds  of  the  scalp  require  to  be  examined  thoroughly;  their 
margins  cut  out,  and  often  the  whole  of  their  surface,  to  get  rid  of  dirt 
particles  that  are  so  frequently  ground  into  them.  In  the  same  way, 
the  surface  of  exposed  bone  ought  to  be  chiselled  off  whenever  there  is 
any  evidence  of  ingraining  with  dirt;  and  if  there  be  any  doubt  as  to  a 
wound  having  been  made  aseptic,  it  is  better  to  leave  it  open  and  allow 
it  to  granulate,  rather  than  to  suture  it  up  and  fail. 

Abscesses  require  to  be  drained;  and,  of  the  three  tjrpes  of  infection, 
they  offer  the  most  hopeful  outlook. 

A  thrombosed  sinus  when  accessible  should  be  opened  up  freely, 
the  infected  clot  removed  and  the  lumen  of  the  vessel  packed.  If  a 
transverse  or  sigmoid  sinus  be  involved,  ligation  of  the  internal  jugular 
vein  in  the  neck  should  be  carried  out,  in  the  hope  of  preventing  dis- 
semination of  infected  emboli.  While  the  prognosis  in  these  cases  is 
not  good,  it  is  not  quite  so  hopeless  as  in  the  meningeal  cases,  almost 
every  one  of  which  is  fatal. 

Head  injuries  can  undoub^-edly  act  as  a  predisposing  cause  to  the 
onset  of  tuberculous  meningitis;  and  it  is  not  less  certain  that  in  a 
patient  with  syphilitic  infection  a  cerebral  trauma  may  be  a  cause  of  a 
syphiHtic  meningitis. 

THE  AFTER-EFFECTS  OF  HEAD  INJURY 

Any  patient  who  has  sustained  an  injury  to  the  head,  and  especially 
one  which  has  caused  unconsciousness,  may  develop,  soon  or  late,  one 
or  other  of  the  following  conditions,  (i)  traumatic  cephalalgia,  (2) 
traumatic  psychasthenia,  (neurasthenia)  {^)  traumatic  epileps> .  (4) 
insanity. 

Traumatic  cephalalgia  is  due  to  irritable  or  painful  scars,  sclerosis  of 
bone,  irregularities  of  the  internal  table  of  the  skull,  cysts  or  thickenings 
of  the  membranes,  or  to  oedema  of  the  brain  or  adhesions  of  the  mem- 
branes to  the  brain.  The  headaches,  frequently  made  worse  by  sudden 
movements  of  the  head,  are  either  generalized  or  local,  the  latter  often 
neuralgic  in  type;  and  either  may  exist  with  or  without  local  tenderness 
on  percussion.  Treatment  is  by  rest  and  such  drugs  as  aspirin  and 
phenacetin  internally.  These  cases  of  localized  headache  (particularly 
if  associated  with  local  tenderness)  are  at  times  benefited  by  trephin- 
ing. When  this  is  done  the  dura  mater  ought  always  to  be  incised  to 
permit  of  an  examination  of  its  own  texture  and  the  state  of  the  under- 
lying soft  membranes  and  brain. 


TRAUMATA   OF   THE    SKULL   AND    CONTENTS  63 

Traumatic  psychasthenia  (neurasthenia)  like  traumatic  epilepsy 
and  insanity  is  more  prone  to  develop  in  a  patient  in  whom  there  is  a 
family  predisposition  to  neurotic  states.  Any  of  the  three  conditions 
may  develop  after  what  are  comparatively  slight  head  injuries,  just 
the  type  of  case  which  there  may  be  a  tendency  to  treat  too  lightly. 

Traumatic  psychasthenia  results  from  "psychical  shock."  "It 
may  be  that  it  is  the  result  of  bio-chemical  or  bio-physical  interference 
with  the  function  of  the  neurones  which  form  the  substratum  of  con- 
sciousness" (Mott).  Weber  believes  that  minute  hemorrhages  with 
the  small  cell  exudation  around  may  not  only  cause  transient  brain 
disturbance  but  can  lead  to  permanent  changes. 

Patients  suffering  from  the  slight  degrees  of  this  condition  show  no 
outward  change  in  character  but  there  is  a  disturbance  in  their  powers 
of  perception,  with  or  without  loss  of  memory.  The  loss  of  memory 
may  concern  events  prior  to  the  accident,  or  details  regarding  the 
occurrence  of  the  accident,  or  there  may  be  a  permanent  impairment  of 
the  power  of  remembering  facts. 

In  more  severe  cases  there  is  an  inability  to  maintain  mental  effort. 
Patients  become  irresolute,  fear  lest  they  make  mistakes,  cannot 
manage  their  money  matters,  suffer  from  insomnia,  and  become 
morose  or  hypochondriacal,  and  if  there  is  any  tendency  to  insanity, 
may  develop  delusions. 

In  the  severest  type  there  is  pronounced  mental  confusion  following 
upon  a  somnolent  stage,  associated  with  delirium  and  sometimes  with 
hallucinations.  There  is  disturbance  of  orientation  of  time  and  space, 
and  there  is  diminution  in  the  powers  of  perception.  Patients  make 
mistakes  in  the  identification  of  persons,  and  there  is  loss  of  memory 
{'^Korsakow^s  psychosis^'). 

Following  upon  injuries  to  the  skull,  especially  in  countries  where 
the  law  decrees  that  compensation  shall  be  paid  for  industrial  and 
other  accidents,  there  is  a  remarkable  tendency  to  exaggerate  symptoms 
and  even  to  simulation;  and  it  is  not  always  easy  to  distinguish  between 
the  genuine  and  the  simulated  case.  The  malingerer  probably  tends 
to  overdo  it.  The  real  sufferer  exhibits  a  tendency  to  lethargy,  cannot 
rouse  himself,  likes  to  be  alone,  and  suffers  loss  of  memory;  while  the 
malingerer  can  often  remember  and  describe  in  great  detail  the  events 
that  occurred  at  the  time  of  the  accident,  and  enjoys  companionship. 

Traumatic  epilepsy  follows  upon  direct  irritation  of  the  brain,  the 
result  of  thickenings  or  depressions  of  the  internal  table,  meningeal  or 
cortical  changes,  scars,  cysts,  etc. 


64  REGIONAL   SURGERY 

In  persons  with  a  latent  tendency  to  epilepsy  the  outbreak  of  the 
active  manifestations  of  that  disease  can  be  Hghted  up  by  cerebral 
traumatism  of  even  the  slightest  degree,  and  where  no  obvious  lesions 
can  be  discovered  microscopically.  In  such  cases  the  epilepsy  is  always 
generaHzed  in  t>'pe. 

In  the  class  with  clearly  evident  lesions  the  epilepsy  may  be  either 
generalized  or,  if  the  lesion  be  in  the  neighborhood  of  the  specialized 
centers  of  the  brain,  may  be  Jacksonian  in  type.  The  treatment  of 
these  conditions  must,  on  the  whole,  be  considered  as  decidedly  un- 
satisfactory. The  hopes  that  were  raised  in  the  early  days  of  surgical 
interference  in  this  class  of  patient  have  not  been  realized. 

The  cases  of  generalized  epilepsy  are  not  suited  for  surgical  treat- 
ment. Those  cases  in  which  there  is  a  definite  Jacksonian  seizure 
following  upon  trauma,  and  where  there  is  no  neurotic  history,  offer 
the  best  chance  of  amelioration  or  cure  by  surgery,  and  the  earlier  the 
operation  is  done  the  better. 

Traumatic  Insanity. — While  it  is  quite  clear  that  insanity  can  follow 
upon  injury  to  the  brain,  the  frequency  with  which  it  occurs  is  variously 
estimated.  It  is  probable  that  trauma  is  a  rare  cause.  Insanity  may 
follow  as  a  direct  result  of  the  injury  but  a  predisposing  neurotic  element 
is  of  far  greater  importance.  In  some  instances  an  injury  leading  to 
psychasthenia  develops  into  insanity,  or  insanity  may  follow  on  a  case 
of  traumatic  epilepsy. 

General  paralysis  of  the  insane  may  be  lighted  up  by  cerebral 
injury  in  a  patient  predisposed  to  it  {i.e.,  a  syphihtic).  Koppen 
describes  under  the  term  "Dementia  post-traumatica,"  a  condition 
which  is  hable  to  be  mistaken  for  general  paralysis,  but  which  occurs 
without  gross  pathological  findings. 

The  treatment  of  traumatic  insanity  is  altogether  unsatisfactory. 
Operation  is  justified  only  where  there  is  a  definite  localizing  sign  or 
symptom. 

A^  has  been  shown  above,  the  skull  may  have  to  be  openeid  tem- 
porarily or  permanently  for  a  varied  series  of  conditions  arising  from 
traumatism.  Thus,  after  certain  fractures  it  will  be  necessary  to 
readjust  (by  elevation  of  fragments  in  the  majority  of  cases  but  by 
depression  in  a  certain  minority)  the  deformity  which  has  been  brought 
about. 

In  a  large  proportion  of  cases  these  deformations  are  subcutaneous 
and  closed;  so  that,  during  the  process  of  exposing  them,  hemorrhage 
from  the  vessels  of  the  scalp  has  to  be  dealt  with;  and  various  measures 


TRAUMATA  OF  THE  SKULL  AND  CONTENTS  65 

have  been  proposed  and  adopted  to  control  it.  A  rubber  tourniquet 
placed  round  the  lowest  level  of  the  scalp,  passing  below  the  occipital 
protuberance  and  the  frontal  eminences,  is  employed  by  some  surgeons; 
or  the  hemostatic  pins  of  Vorschiitz;  or  the  compression  bars  of  Kredl; 
or  sutures  passed  through  and  under  the  scalp  and  surrounding  the 
whole  area  of  the  operation,  are  used  by  others;  while  others  again 
trust  to  catching  the  vessels  in  forceps  as  they  are  divided. 

Excepting  the  cases  (and  they  are  comparatively  rare  after  traumat- 
ism) where  it  is  necessary  to  expose  a  large  area  of  bone  by  turning 
down  a  considerable  flap  of  the  scalp,  it  will  generally  be  found  sufficient 
to  rely  upon  the  use  of  forceps  to  take  the  vessels  as  they  are  cut ;  but  for 
the  more  extensive  operations  the  writer  prefers  the  encircling  sutures. 

Whenever  it  is  feasible  it  ought  to  be  the  aim  to  reimplant  any  bone 
which  it  has  been  found  necessary  to  remove  during  an  operation;  but 
this  is  only  possible  when  one  is  assured  of  the  asepsis  of  the  wound. 
When  one  is  dealing  with  a  closed  fracture  there  ought  to  be  no  difficulty 
in  this  respect;  and  in  the  case  of  an  open  fracture  it  may  often  be  done 
with  success.  Where  the  outer  surface  of  the  bone  fragments  is 
ingrained  with  dirt,  if  the  fragments  are  split  along  the  diploe,  the 
internal  table  can  often  be  reimplanted. 

When  the  skull  is  opened  in  infective  diseases  the  bone  cannot  be 
replaced;  and  it  may  be  necessary  or  advisable  to  close  the  gap  at  a 
later  period  by  one  of  the  methods  already  alluded  to. 

In  many  operations  one  requires  to  open  the  skull  over  a  definite 
area  of  the  brain;  and  for  this  purpose  it  is  necessary  that  one  should  be 
able  to  mark  out  upon  the  scalp  the  principal  fissures  and  areas  of  the 
subjacent  brain. 

Several  methods  have  been  employed  for  this  object;  in  the  writer's 
opinion  the  simplest  and  most  satisfactory  is  that  of  Professor  Chiene, 
which  entirely  does  away  with  the  use  of  a  cyrtometer,  and  is  easy  to 
bear  in  mind.  The  primary  lines  are  drawn  from  bony  points  which 
are  readily  recognized.  Mr.  Chiene's  directions  are  as  follows  (see 
Figs.  7  and  8). 

"The  head  being  shaved  find  in  the  mesial  line  of  the  skull  between 
the  glabella  (G)  and  the  external  occipital  protuberance  (0)  the  follow- 
ing points:  First,  the  mid-point  {%)  M;  second,  the  three-quarter 
point  {%)  T;  third  the  seven-eighth  point  S. 

"Find  also  the  external  angular  process  (E),  and  the  root  of  the 
zygoma  (P),  immediately  above  and  in  front  of  the  external  auditory 
meatus. 


66 


REGIONAL   SURGERY 


Fig.  8. — Cranio-cerebral  topography.     Chiene's  lines  in  relation  to  main  fissures  and  area& 
of  the  brain.     (Afler  Sliks-Cunninghatn' s  Anatomy.) 


TRAUMATA   OF   THE    SKULL   AND    CONTENTS  67 

"Having  found  these  five  points,  join  EP,  PS,  and  ET. 

"Bisect  EP  and  PS  at  N  and  R.     Join  NM  and  RM. 

"Bisect  also  AB  at  C,  and  draw  CD  parallel  to  AM," 

The  parallelogram  MDCA  corresponds  to  the  Rolandic  area;  the 
ascending  frontal  and  parietal  convolutions  with  the  fissure  of  Rolando 
between  them,  and  the  anterior  branch  of  the  middle  meningeal  artery. 

The  line  MA  corresponds  to  the  superior  and  inferior  precentral 
sulci;  and  if  it  is  trisected  at  K  andL,  these  points  will  correspond  to  the 
origins  of  the  superior  and  inferior  frontal  sulci. 

The  point  A  corresponds  to  the  Sylvian  point  of  the  fissure  of  Syl- 
vius, while  AC  follows  the  posterior  horizontal  limb  of  that  fissure. 

The  pentagon  ABRPN  corresponds  to  the  temporo-sphenoidal 
lobe,  with  the  exception  of  its  apex  which  is  a  little  in  front  of  N,  with  the 
center  for  taste  and  smell.  The  parallel  sulcus  lies  three-quarters  of 
an  inch  below  the  line  AB.     The  angular  gyrus  is  at  B. 

To  mark  out  the  fissure  of  Rolando  on  the  scalp  find  the  mid-point 
between  the  glabella  and  occipital  protuberance,  and  at  a  point  half 
an  inch  posterior  to  it  draw  a  line  3%  in.  down  and  forward  at  an 
angle  of  67°  to  the  sagittal  line.  Chiene's  method  of  finding  the  angle 
of  67°  is  useful:  take  a  sheet  of  paper  and  fold  it  to  half  a  right  angle 
(45°)  and  again  to  a  quarter  of  a  right  angle  22.5°  when  an  angle  of 
67.5°  is  obtained. 


BRANCHIAL  SYSTEM 


SECTION  IV 
DEVELOPMENT 

By 
J.  FAIRBAIRN  BINNIE,  A.  M.,  C.  M.,     F.  A.  C.  S. 

The  ovum  or  primary  cell  after  fertilization  undergoes  segmentation, 
i.e.,  it  divides  into  two  cells  each  of  which  in  turn  divides  into  two  and 
thus  the  cells  increasing  by  geometrical  progression,  a  mass  of  cells  soon 
results,  the  mulberry  mass  or  morula  (Fig.  9).  Soon  a  cavity,  situated 
eccentrically,  appears  in  the  morula  and  the  mass  of  cells  is  converted 
into  a  hollow  sphere,  blastodermic  vesicle,  consisting  of  a  covering 
membrane  (zona  pellucida  lined  by  a  single  layer  of  cells  called  the 


Fig.  9. — Diagram  of  section  through 
a  mammalian  ovum  at  the  morula  stage. 
{Morris'  Anatomy.) 


Fig.  10. — Diagram  of  section  of  a  mam- 
malian ovum  showing  the  inner  cell  mass. 
(Morris'  Anatomy.) 


trophoblast.  Fig.  10).  At  one  point  on  the  inner  surface  of  the  vesicle 
there  is  a  mass  of  cells,  the  inner  cell  mass,  which  when  looked  at  from 
the  surface  forms  an  opaque  area  on  the  vesicle  to  which  is  given  the 
name  embryonic  area  (Fig.  11). 

In  the  more  superficial  part  of  the  inner  cell  mass  a  cavity  appears 
(Fig.  12),  the  amniotic  cavity  "and  from  the  cells  which  form  its  floor 
the  embryo  develops,  the  remaining  portion  of  the  vesicle  giving  origin 
to  structures  concerned  in  the  nutrition  of  the  embryo"  (ISIcMurrich). 
The  cells  which  form  the  embryo  become  differentiated  and  arranged  in 

69 


70 


REGIONAL   SURGERY 


two  layers,  the  ectoderm  (epiblast)  and  the  endoderm  (hypoblast). 
The  ectoderm  forms  the  floor  of  the  amniotic  cavity  while  the  endoderm 
spreads  itself  over  the  inner  surface  of  the  vesicle.     Between  the  ecto- 


mff 


Fig.  II. — A,  Side  view  of  ovum  of  rabbit  seven 'days  old  (Kolliker);  B,  embryonic  disk 
of  a  mole  (Heape);  C,  embryonic  disk  of  a  dog's  ovum  of  about  fifteen  days  (Bonnet), 
ed,  Embryonic  disk;  hn,  Hensen's  node;  f}tg,  medullary  groove,  ps,  primitive  streak;  va, 
vascular  area. 

and  endoderm  a  third  layer  of  cells  soon  appears,  the  mesoderm  or 
mesoblast.  These  three  layers  become  the  parents  of  very  different 
structures.     The  ectoderm  provides  the  epidermis  and  the  nervous 


ECTODERM 


MESODERM 


ENDODERM 


Fig.  12. — Diagram  of  section  of  a  mammalian  ovum  showing  the  amniotic  cavity  and  the 
embryonic  germinal  layers.     (Morris'  Anatomy.) 

system;  the  endoderm  provides  the  mucous  membrane  of  the  digestive 
tract  with  its  derivatives  (liver,  lungs,  thyroid,  etc.),  as  well  as  the 
urinary  bladder;  the  mesoderm  provides  the  remaining  organs  (mus- 
cles, bones,  etc.). 


DEVELOPMENT 


71 


About  this  time  a  longitudinal  groove  appears  on  the  surface  of  the 
embryonal  area  or  disc,  the  medullary  groove  bounded  by  two  ridges 
(medullary  ridges)    (Figs.   13  and   14).     As  the  groove  deepens  the 


EINDO 


Fig.  13.— M,  Medullary  groove;  iV,  notochord. 

summits  of  the  ridges  come  together  and  unite  so  that  the  medullary 
groove  becomes  a  canal  (medullary  or  neural  canal)   which  runs  the 


Neural  groove 


Mesodermic  somite 


Medullary  canal 


Heart 


Umbilical  vein 


Yolk  sac 


Fig.  14. — A  human  embryo  2.5  mm.  in  length.     (AfterlKollmann.) 

whole  length  of  the  embryo.  The  canal  persists  through  life  as  the 
central  canal  of  the  spinal  cord  and  the  brain;  the  lining  of  the  canal 
(ectodermic  cells),  forms  the  central  nervous  system. 


72 


REGIONAL   SURGERY 


At  the  same  time  a  longitudinal  groove  appears  on  the  lower 
surface  of  the  embryonic  disc  (Fig.  13)  resulting  in  the  pinching  off  of 
a  solid  rod  of  endodermic  cells.  This  rod,  the  notochord,  is  not  a 
permanent  structure.  Many  recent  authorities  (Lillie,  Bardeen, 
F.  P.  Johnson)  consider  the  notochord  to  be  mesoblastic  in  origin. 

The  development  of  the  medullary  canal  and  the  notochord  divides 
the  mesoderm  longitudinally  into  two  masses  one  on  each  side  of  the 
middle  line.  Each  of  these  masses  of  mesoderm  splits  into  two  sheets 
one  of  which  remains  in  contact  with  the  ectoderm  (somatic  layer)  the 
other  with  the  endoderm  (splanchnic  layer).  Near  the  medullary 
canal  the  two  layers  of  mesoderm  are  continuous.     A  short  distance 

laterally  from  its  median  edge,  the 
mesoderm  becomes  constricted  by 
longitudinal  grooves  until  it  becomes 
divided  into  a  median  or  dorsal  band 
and  a  lateral  or  ventral  portion. 

The  median  and  lateral  portions 
of  the  mesoderm  are  connected  by  a 
mass  of  cells,  the  intermediate  cell 
mass.  Soon  after  the  median  and 
lateral  portions  of  the  mesoderm 
have  been  differentiated,  the  median 
portion  becomes  divided  transversely 
into  a  series  of  masses  (mesodermic 
somites)  (Fig.  14)  corresponding  to 
the  future  vertebrae.  The  lateral 
portions  of  the  mesoderm  do  not 
transverse  division  into  segments. 
Their  splanchnic  layer  goes  to  form  the  visceral  layers  of  the  per- 
icardium, pleurse  and  peritoneum,  while  their  somatic  layer  lies  in 
contact  with  the  body  wall  forming  the  parietal  pericardium,  pleurae 
and  peritoneum.  The  median  portion  of  mesoderm  forms  the  bones 
and  muscles  of  the  back  and  sends  processes  laterally  between  the 
somatic  layer  of  the  lateral  mesoderm  and  the  ectoderm  to  form  the 
ventral  muscles,  etc. 

In  the  preceding  paragraphs  development  is  described  as  if  the 
embryo  were  a  fiat,  pan-cake-like  structure  consisting  of  three  (later  four) 
layers  of  cells  and  for  a  part  of  the  time  taken  up  by  the  changes  de- 
scribed, this  is  true.  Very  early,  however,  the  edges  of  the  pan-cake 
(embryonic  disc)  consisting  of  ectoderm  above  and  endoderm  below 


Fig.  15. 
undergo    the    above-mentioned 


DEVELOPMENT 


73 


turn  downward  and  inward  until  they  come  close  together  forming 
a  cavity  lined  with  endoderm  which  is  continuous  with  the  endoderm 
lining  the  much  enlarged  blastodermic  vesicle.  As  time  passes  the 
curled-in  edges  of  the  embryonic  disc  unite  in  the  middle  line;  their  line 
of  fusion  being  shown  in  the  linea  alba  of  later  life,  the  umbilicus 
marking  the  spot  where  the  last  communication  persists  between  the 
interior  of  the  embryo  and  its  external  coverings  until  it  is  divided  at 
birth.  The  part  of  the  endoderm  which  is  now  situated  inside  the 
embryo  forms  the  primitive  intestine.  It  has  as  yet  no  opening  other 
than  that  communicating  with  the  yolk  sac.  The  yolk  sac  consists  of 
the  endodermic  lining  of  the  blastodermic  vesicle  which  has  become 
much  separated  from  the  original  wall  of  the  vesicle  and  covered  with 
mesoderm.  The  space  between  the  yolk  sac  and  the  wall  of  the 
blastodermic  vesicle  is  called  the  extraembryonic  ccelom. 


AL^ 


Fig.  i6.  Fig.  17. 

A,  Amniotic  cavuty;   F,  yolk  sac;  X,  extraembryonic  coelom;  AL,  allantois. 

Figure  15  shows  in  diagrammatic  fashion  a  transverse  section  near 
the  middle  of  the  embryo  at  the  stage  of  development  which  has  been 
described. 

No  account  has  yet  been  taken  of  the  formation  of  structures  which 
surround,  protect  and  nourish  the  embryo  while  in  the  uterus.  The 
trophoblast  of  the  enlarging  vesicle  becomes  thickened  and  is  in  direct 
contact  with  the  mucous  membrane  of  the  uterus  in  which  it  lies. 
Processes  grow  outward  from  the  trophoblast  and  penetrate  the  uterine 
mucosa.  Fig.  16  shows  diagrammatically  a  longitudinal  section  of  the 
embryo  lying  beneath  the  amniotic  cavity.  The  mesoderm  has  spread 
out  from  its  original  position  between  the  ecto  and  endoderm  and  has 
covered  not  only  the  yolk  sac  but  has  formed  a  lining  to  the  whole 
vesicle  and  penetrated  between  the  amniotic  cavity  and  the  trophoblast. 
A  process  of  the  extraembryonic  coelom  pushes  its  way  into  themeso- 
dermic  tissue  lying  between  the  amniotic  sac  and  the  trophoblast  (now 
named   chorion)   (Fig.    17)  while    the   amniotic   sac  enlarges  until  it 


74 


REGIONAL  SURGERY 


covers  the  embryo  completely  except  for  that  part  of  its  under  surface 
where  the  primitive  intestine  communicates  with  the  yolk  sac  and  a 
stalk  of  mesoderm  (body-stalk)  passes  out  to  join  the  lining  of  the 
chorion  (Fig.  i8).  Thus  the  embryo  is  now  practically  enveloped 
by  two  sacs,  the  amniotic  sac  next  to  it  and  the  extraembryonic  coelom 
next  to  the  chorion.  As  mentioned  previously,  processes  scattered 
all  over  the  trophoblast  or  chorion  penetrate  the  uterine  mucosa. 
These  increase  greatly  in  size  and  into  them  mesoderm  penetrates  and 
a  very  close  connection  is  formed  between  the  mesoderm  of  the  embryo 
and  the  maternal  uterine  mucosa.     These  two  structures  being  sepa- 


FiG.  i8. 

rated  by  the  trophoblastic  epithelium.  Ultimately  many  of  the  villi 
degenerate  but  those  opposite  the  body-stalk  persist  (placental  villi). 
The  chorion  and  body-stalk  at  their  junction  form  the  placenta; 
the  rest  of  the  body-stalk  forms  the  basis  of  the  umbilical  cord.  From 
the  primitive  intestine  (hind-gut)  at  its  caudal  end  there  grows  off  a 
long  slender  tube  which  pushes  its  way  into  the  body-stalk  (Fig.  17). 
This  is  named  the  allantois.  In  man  the  portion  of  the  allantois  which 
lies  in  the  body-stalk  outside  the  embryo  proper,  is  insignificant;  the 
portion  which  lies  inside  the  embryo  forms  the  urinary  bladder  and  the 
urachus,  a  fibrous  cord  running  from  the  dome  of  the  bladder  to  the 


DEVELOPMENT 


75 


umbilicus  represents,  in  the  adult,  the  unused  portion  of  the  allantois. 
Not  infrequently  the  unused  portion  of  the  allantois  retains  to  a 
greater  or  less  extent  its  tubular  character  and  thus  a  fistula,  lined  with 


Fig.  19. — Embryo  Lr,  4.2  mm.  long.     a}n,  Amnion;  an,  auditory  capsule;  B,  belly-stalk; 
h,  heart;  LI,  lower,  and  Ul,  upper  limb;  Y,  yolk-sac.     (His.) 


mucous  membrane,  may  extend  from  the  umbilicus  to  the  bladder  or, 
when  the  persistence  is  less  complete,  the  allantois  may  form  a  diver- 
ticulum extending  from  the  bladder,  or  a  cyst  along  the  course  of  the 
urachus. 


76  REGIONAL   SURGERY 

As  development  proceeds,  blood-vessels  form  in  the  embryonic  meso- 
derm. Some  of  these  send  prolongations  through  the  mesoderm  of  the 
body-stalk  (allantoic  vessels)  into  the  placental  villi.  Thus  are  formed 
the  vessels  of  the  umbilical  cord.  The  obliterated  hypogastric  arteries 
forming  cords  across  the  lateral  walls  of  the  urinary  bladder  and  up  the 
abdominal  wall  to  the  umbilicus  remain  in  the  adult  mute  witnesses  to 
the  earlier  circulation. 

Very  early  in  development,  even  while  the  embryo  is  still  flat  and 
plate-like  the  head  and  tail  ends  are  differentiated  by  constrictions  from 
the  body  portion  of  the  embryo.  This  differentiation  becomes  much 
more  marked  when  the  embryo  assumes  a  somewhat  cylindrical  shape 
in  the  manner  already  described.  The  head  and  tail  ends  become 
ventrally  flexed  on  the  body,  the  anterior  point  of  flexure  being  the 
cephalic  flexure  which  corresponds  to  the  position  of  the  middle  of 
three  expansions  at  the  anterior  end  of  the  medullary  tube  forming 
the  anterior,  middle  and  posterior  brain  vesicles  (Fig.  19). 

About  the  thirteenth  day  a  depression  appears  immediately  below 
the  anterior  cerebral  vesicle.  The  depression  deepens  until  it  is  sepa- 
rated from  the  primitive  gut  merely  by  a  thin  layer  of  ectoderm  and 
a  thin  layer  of  endoderm  (pharyngeal  membrane) ,  there  being  at  this 
place  no  mesoderm  present.  The  depression  is  the  primitive  oral 
cavity  or  stomodceurn. 

Soon  the  pharyngeal  membrane  disappears  and  the  oral  cavity  opens 
into  the  anterior  end  of  the  primitive  gut  now  called  the  primitive 
pharynx. 

By  the  third  week  of  development  a  series  of  arches  separated  by 
grooves  (Fig.  1 9)  appear  on  each  side  of  the  head  end  of  the  embryo.  The 
arches  are  formed  of  mesodermic  rods;  between  the  rods  the  mesoderm 
is  absent  and  thus  grooves  or  clefts  are  formed  both  on  the  pharyngeal 
and  external  surfaces.  In  mammals  the  pharyngeal  grooves  are  sepa- 
rated from  the  external  grooves  by  a  membrane  consisting  of  both  endo 
and  ectoderm.  In  fish  this  membrane  is  absent  and  the  clefts  persist 
as  the  gills  by  means  of  which  the  blood  of  the  fish  is  oxygenated. 

In  a  four  weeks'  embryo  exhibited  by  F.  P.  Johnson  there  were  three 
distinct  arches  with  the  beginning  of  a  fourth.  Ultimately  in  the 
human  embryo  four  clefts  and  five  arches  develop  on  each  side  of  the 
body,  the  last  arch  lying  posteriorly  to  the  fourth  cleft  and  not  being 
very  sharply  defined  along  its  posterior  margin  (McMurrich). 

The  fifth  branchial  arch  in  man  is  entirely  rudimentary.     The 


DEVELOPMENT 


77 


second  branchial  arch  in  lower  animals,  e.g.,  fish,  is  cartilaginous, 
but  in  man  it  becomes  fibrous  except  at  both  extremities;  its  upper 
end  becomes  the  styloid  process  of  the  temporal  bone,  its  lower  end 
becomes  the  lesser  horn  of  the  hyoid  bone  while  its  intermediate  and 
major  portion  forms  the  stylo-hyoid  ligament.  The  same  arch  forms 
the  anterior  pillars  of  the  fauces  which  in  the  adult  constitute  the 
dividing  line  between  the  oral  cavity  and  the  pharynx. 

The  third  arch  gives  rise  to  the  body  and  greater  horn  of  the  hyoid 
and  to  the  posterior  pillars  of  the  fauces 

The  fourth  and  fifth  arches  partake  in  the  formation  of  the  thyroid 
cartilage. 


Fig.  20. — Five  successive  stages  in  the  development  of  the  anterior  wall  of  the  bucco- 
pharynx,  showing  the  formation  of  the  tongue,  the  thyroid  gland  and  the  epiglottis. 
vix.  Maxillary  arch;  hy,  hyoid  arch;  br^,  br^,  br^,  the  three  last  branchial  arches;  pb, 
floor  of  the  mouth;  ti,  tuberculum  impar;  bl,  base  of  tongue  formed  by  the  fusion  of  the 
median  ends  of^the  2d  and  3d  arches;  /,  furcula;  rudiment  of  the  epiglottis,  the  arytenoid 
cartilages  and  the  ary-epiglottic  folds;  e,  epiglottis;  /,  laryngeal  orifice.  {Poirier  and 
Cliarpey,  after  His.) 

During  development  the  second,  third  and  fourth  arches  of  one  side 
become  united  in  the  middle  line  with  the  corresponding  arches  on  the 
other  side  to  form  the  floor  of  the  mouth. 

In  the  middle  line  on  the  oral  surface  of  the  first  and  second  arches 
a  prominence  forms  (tuberculum  impar)  from  which  is  developed 
the  anterior  portion  of  the  tongue  (Fig.  20).  On  the  pharyngeal  surface 
of  the  fused  second  and  third  arches  there  appear  two  prominences 


78 


REGIONAL   SURGERY 


close  together  immediately  behind  the  tubercular  impar;  these  form 
the  base  of  the  tongue.  The  whole  tongue  thus  results  from  the 
union  of  three  masses  of  tissue.  When  three  masses  of  any  material 
are  placed  in  contact  each  with  both  of  the  others  there  is  one  point 
where  contact  is  often  imperfect.  This  is  true  in  the  case  of  the 
tongue  and  the  result  is  a  tube  or  canal,  lined  with  endoderm,  passing 
through  the  thickness  of  the  tongue.     Normally  this  canal  becomes 


Fig.  21.  Fig.  22. 

Fig.  21. — Profile  human  embryo,  third  week,  br,  Branchial  arches;  fb,  branchial 
clefts;  c,  anterior  cerebral  vesicle;  v,  auditory  vesicle;  co,  heart;  pv,  ventral  pedicle;  vo, 
umbilical  vesicle;  ch,  chorion.     (Poirier  and  Charpey,  after  His.) 

Fig.  22. — Human  embryo,  third  week.  Opened  anteriorly,  m,  Sup.  maxilla;  mx, 
inf.  maxilla  (ist  arch);  hy,  hyoid  arch;  br^,  br*,  br^,  third,  fourth  and  fifth  arches;  fb,  sub- 
branchial  fossa;  pk,  pharynx  continuous  with  oe  oesophagus,  e  stomach  and  with  a  short 
segment  of  intestine  which  passes  through  the  open  umbilical  pedicle  into  the  umbilical  or 
viteUine  vesicle;  c,  anterior  cerebral  vesicle  with  the  two  ocular  vesicles  0;  cv,  cardinal 
vein;  cw,  Wolfi&an  canal.     (Poirier  and  Charpey,  after  His.) 

obliterated  except  at  its  superior  end  where  the  foramen  caecum  persists 
as  a  reminder  of  its  existence.  The  endoderm  of  the  lower  end  of  the 
canal  provides  material  for  the  median  portion  of  the  thyroid  gland. 
Persistence  of  the  canal  (thyreo-glossal  duct)  gives  rise  to  various 
tumors  and  fistulas.  The  line  of  union  between  the  tuberculum  impar 
and  the  other  two  masses  of  tissue  is  indicated  in  later  life  by  a  V-shaped 
mark  on  the  tongue,  the  foramen  caecum  being  at  the  apex  of  the  V. 


DEVELOPMENT 


79 


//p~ 


mxp-^ 


Behind  the  origins  of  the  base  of  the  tongue  on  the  inner  surface  of  the 
anterior  wall  of  the  pharynx  an  elongated  elevation  appears  (the  furcula) 
in  the  middle  line  of  which  there  forms  a  split  or  crevasse  (Fig.  20). 
The  anterior  end  of  the  furcula  forms  the  epiglottis;  the  split  or  crevasse 
extends  posteriorly  into  the  future  trachea.  From  the  furcula  there 
also  are  formed  the  arytenoid,  the  ary-epiglotidean  folds,  etc.  As 
Prenant  writes,  "thus  the  orifice  of  the  larynx  becomes  surrounded  by 
a  horseshoe-shaped  ridge,  thickened  anteriorly  and  at  its  posterior 
extremities  and  projecting  prominently  into  the  pharyngeal  cavity. 
This  ridge  is,  in  turn,  surrounded  by  an  arciform  gutter  (Fig.  20)  of 
which  the  two  extremities  are 
deep  (subbranchial  fossae);  by 
means  of  this  gutter  the  borders 
of  the  laryngeal  cleft  are  sepa- 
rated from  the  anterior  wall  of 
the  pharynx." 

When  first  formed  the  bran- 
chial arches  are  in  series  one  be- 
hind the  other  (Figs.  21  and  22), 
one  being  exposed  almost  as 
completely  as  another;  soon 
however  the  upper  or  anterior 
arches  slide  downward  over  the 
lower  ones  pushing  these  inward 
and  in  part  covering  them  (Fig. 
20)  until  the  fourth  and  third 
branchial  clefts  are  hidden  in  an 
irregular  cavity  lying  between 

the  walls  of  the  neck  (branchial  arches)  and  the  thoracic  wall.  His 
named  this  cavity  the  precervical  sinus.  The  entrance  to  the  sinus 
is  bounded  above  (or  anteriorly)  by  the  second  or  hyoid  arch  which 
develops  a  small  process  backward  (or  downward)  covering  the  sinus 
and  corresponding  to  the  operculum  of  fish.  (The  shark  and  dogfish 
have  no  operculum.)  The  opercular  process  at  last  fuses  with  the 
lateral  wall  of  the  body  and  the  sinus  becomes  closed.  Persistence  of 
the  sinus  gives  rise  to  various  fistulae  and  tumors. 

As  already  mentioned,  the  branchial  clefts  persist  in  such  creatures 
as  fish  and  perform  most  important  functions;  in  man,  however,  they 
normally  apparently  disappear.  Their  total  disappearance  is,  however, 
more  apparent  than  real,  as   they  provide  the  material  for  the  de- 


F1G.23. — Face  of  embryo  of  8  mm.  mxp. 
Maxillary  process;  np,  nasal  pit;  os,  oral  fossa; 
pg,  processus  globularis.     {His.) 


8o 


REGIONAL   SURGERY 


velopment  of  various  organs.  The  third  pharyngeal  clefts  provide  the 
endoderm  from  which  the  thymus  gland  is  formed;  the  fourth  pharyn- 
geal clefts  provide  the  material  for  the  lateral  lobes  of  the  thyroid  gland. 
The  first  branchial  arch  (mandibular  arch)  requires  very  special 
study  because  from  it  in  conjunction  with  a  median  process  arising 
from  the  anterior  end  of  the  embryo,  are  developed  the  face,  jaws, 
palate,  etc. 

The  first  branchial  arch  of  one  side  unites  with  that  of  the  other 
side  to  form  the  lower  jaw  and  lip  (Fig.  23) .     From  the  upper  or  anterior 

surface  of  the  first  arch  on  each  side  there 
arises  a  process  (superior  maxillary  proc- 
ess) which  grows  inw.ard  toward  the  median 
line  but  does  not  meet  its  fellow  of  the 
opposite  side,  being  separated  from  it  by 
a  process  coming  down  from  the  median 
part  of  the  extreme  cephalic  end  of  the 
embryo  (f  ronto-nasal  process) .  Very  early 
in  development  the  fronto-nasal  process 
consists  of  a  thickening  of  the  ectoderm. 
In  this  on  each  side  there  forms  a  pit — 
olfactory  or  nasal  pit.  The  edges  of  these 
pits  become  much  raised  and  prominent 
except  at  the  lower  or  oral  part  of  their 
circumference.  Soon  the  pits  become 
converted  into  deep  grooves  running 
downward  to  join  the  cleft  existing  above 
the  superior  maxillary  process.  As  the 
two  edges  of  each  olfactory  pit  or  furrow 
become  more  prominent  they  form  the  ex- 
ternal and  the  internal  nasal  processes.  The  two  inner  nasal  processes 
become  fused  and  form  the  most  prominent  parts  of  the  nose  as  well  as 
its  columella  and  the  lunula  of  the  upper  lip.  The  external  nasal 
processes  form  the  sides  and  the  alae  of  the  nose. 

Albrecht  considers  that  the  external  nasal  process  extends  down- 
ward to  the  mouth  (Fig.  24,  A)  to  form  a  segment  of  the  upper  lip  ex- 
ternal, to  the  lunula.  Trendelenburg  believes  that  the  external  nasal 
process,  while  it  contributes  to  the  formation  of  the  lip  external  to  the 
lunula  does  not  reach  the  lip  margin  (Fig.  24.,  B).  The  views  of 
Albrecht  and  Trendelenburg  are  important  as  explaining  the  inci- 
dence of  various  malformations  (Fig.  25). 


Fig.  24. — a,  a,  Nares;  e,  e,  lower 
eye  lids;  fb,  gb,  fissures  between  the 
internal  and  external  nasal  proc- 
esses; X,  X,  margin  of  upper  lip; 
fbe,  external  nasal  process  accord- 
ing to  Albrecht;  fcde,  external 
nasal  process  according  to  Trendel- 
enburg.    {Trendelenburg.) 


DEVELOPMENT 


8l 


The  fissures  or  spaces  existing  between  the  external  nasal  and  the 
superior  maxillary  processes  on  each  side  are  known  as  the  naso- 
lachrymal  or  lachrymal  grooves.  At  or  just  above  the  upper  end  of 
the  lachrymal  grooves  the  optic  vesicles  have  already  formed  and  from 
them  the  retinae  of  the  eyes  are  developed. 

An  epithelial  cord  sequestrated  in  the  depth  of  each  lachrymal 
groove  gives  rise  to  the  lachrymal  ducts  leading  from  the  eyes  to  the 
nasal  cavity.  The  superior  maxillary  process  of  each  side  unites  with 
the  fronto-nasal  process  to  form  the  cheek  and  upper  lip — the  lunula  or 
groove  in  the  middle  of  the  upper  lip  remaining  as  a  representative  of 
the  fronto-nasal  process.  As  these  superficial  changes  are  occurring 
deeper  changes  may  be  observed  taking  place.     The  deeper  part  of  the 


Albrecht's  view. 


Fig. 


Trendelenburg's  view. 


fronto-nasal  process  becomes  very  thin  and  forms  the  anterior  portion 
of  the  septum  of  the  nose,  the  posterior  portion  of  which  is  separately 
developed  from  another  process  arising  from  the  skull  (ethmoidal 
plate).  The  deeper  part  of  the  fronto-nasal  process  corresponding  to 
that  portion  between  the  two  olfactory  pits  (internal  nasal  processes) 
forms  the  intermaxillary  or  premaxillary  bone  in  which  the  incisor 
teeth  are  developed  (sometimes  called  os  incisivum). 

From  each  superior  maxillary  process  horizontal  projections  or 
plates  grow  toward  the  median  fine  (palatal  plates  or  processes)  to 
join  with  the  corresponding  parts  of  the  fronto-nasal  process  and  form 
a  division  between  the  oral  and  nasal  cavities  (Fig.  26).     Thus  the 


82  REGIONAL   SURGERY 

palate  is  formed  by  the  junction  of  the  palatal  processes  of  the  superior 
maxillary  processes  with  the  nasal  septum  and  with  the  intermaxillary 
bone,  the  intermaxillary  bone  itself  being  the  result  of  the  fusion  of  the 
deeper  parts  of  the  two  internal  nasal  processes. 

Albrecht,  noting  that  the  intermaxillary  bone  has  two  foci  of 
ossification  on  each  side,  argues  that  it  is  developed  from  a  correspond- 
ing number  of  processes,  i.e.,  that  the  external  nasal  process  is  also 
providing  material  for  the  development  of  this  bone.  Warinski's 
researches  are  generally  believed  to  dispose  of  the  Albrecht  theory,  but 
to  the  author  it  is  strongly  supported  by  the  fact  that  fissures  or  clefts 
due  to  non-closure  of  the  lachrymal  fissure  do  not  necessarily  follow  the 
line  marked  out  by  that  common  deformity,  hare-lip.  The  cleft  may 
extend  from  the  middle  of  the  lower  eyelid  downward,  well  external 
to  the  ala  of  the  nose,  and  involve  the  upper  lip  external  to  the  lunula. 


Fig.  26. — View  of  the  roof  of  the  oral  fossa  of  embryo  showing  the  lip-groove  and  the 
formation  of  the  palate.     {His.) 

In  man  the  intermaxillary  bone,  early  in  intra-uterine  hfe,  becomes 
imited  to  the  superior  maxillary  process;  in  the  lower  apes,  the  car- 
nivora,  etc.,  this  bone  retains  its  independence  and  assumes  a  position 
well  in  front  of  the  palate.  In  such  animals  the  bone  is  frequently 
known  as  the  premaxillary  bone.  In  certain  cases  of  complete  cleft 
palate  the  intermaxillary  bone,  not  having  united  to  the  maxillse,  is 
carried  forward  by  the  growth  of  the  nose  until  it  assumes  a  position 
roughly  analogous  to  that  seen  in  the  animals  referred  to  above. 

Just  above  the  first  branchial  cleft  there  early  appears  a  thickening 
of  the  ectoderm.  This  thickening  soon  sinks  into  the  embryo  and 
becomes  a  pit.  The  mouth  of  the  pit  quickly  becomes  narrow  and  at 
last  disappears,  leaving  a  vesicle  lined  with  ectoderm  inside  the  embryo. 

This  is  the  auditory  vesicle  or  otocyst  and  it  soon  becomes  con- 


DEVELOPMENT 


83 


nected  with  the  central  nervous  system  by  the  acoustic  nerve.  The 
auditory  vesicle  provides  the  ectoderm  out  of  which  develop  the 
essential  organs  of  hearing  and  of  equilibrium,  viz.,  the  internal  ear. 
The  middle  and  external  ears  are  merely  accessory  organs  of  hearing  and 
have  a  different  origin. 

The  external  ear  is  developed  from  the  ectodermic  portion  of  the 
first  branchial  cleft  and  the  first  and  second  arches.  The  middle  ear  is 
developed  from  the  visceral  side,  i.e.,  the  endodermic  side  of  the  same 
structures.  The  middle  is  separated  from  the  external  ear  by  the  mem- 
branum  tympani,  which  is  formed  from  the  occluding  membrane  of  the 
first  cleft  (ectoderm  externally  and  endoderm  internally)  and  partly 
from  the  first  and  second  arches. 


—  Auditory  Vesicle 


Fig.  27. 


Inferior  Maxilla 


Superior  Maxilla 
-Embryo  (11  mm.).     (His.)     1-2-3-4-5  Auricular  tubercles;  c,  hyoidean  helix. 


'  Around  the  first  cleft  six  tubercles  appear,  three  arising  from  the 
first  arch  and  three  from  the  second.  His  distinguishes  these  tubercles 
by  the  numerals  i,  2,  3,  etc.  Behind  the  three  tubercles  arising  from 
the  second  arch  a  fold  of  skin  forms  (C,  Fig.  27),  entirely  independent 
of  the  tubercles;  this  has  been  named  the  hyoidean  helix. 

It  is  believed  that  tubercle  i  forms  the  tragus;  2  and  3  contribute 
to  form  the  helix;  4  the  antehelix;  while  the  hyoidean  helix  forms  the 
lobule  and  a  large  part  of  the  helix.  Schwalbe  thinks  that  another 
fold  of  skin  (mandibular  helix)  also  aids  in  forming  the  helLx. 

Guibe  writes:  "At  the  beginning  of  the  third  month,  the  posterior 
and  superior  part  of  the  pinna  begins  to  separate  from  the  head. 
Toward  the  middle  of  pregnancy  union  between  the  tubercles  has 
terminated;  all  the  definite  parts  of  the  ear  are  recognisable  except  the 


84  REGIONAL   SURGERY 

concha  which  develops  later."  The  formation  of  an  operculum  which 
covers  all  the  gills  in  fish  and  the  absence  of  this  large  operculum  in 
sharks  have  been  already  noted.  Bland-Sutton  points  out  that  in 
sharks  a  fold  of  skin  is  formed  from  the  branchial  arch  in  front  of  each 
fissure,  and  so  an  operculum  is  formed  for  each  fissure  or  gill  cleft. 
"In  mammalian  embryos  a  shght  prominence  or  tubercle  is  for  a  time 
visible  anterior  to  each  of  these  clefts.  In  most  cases  the  tubercles 
disappear  from  the  posterior  bars,  but  those  in  relation  with  the 
anterior  cleft  enlarge  and  are  joined  by  accessory  tubercles  to  form  the 
pinna.  Thus  embryology  has  taught  me  to  regard  the  pinna  as  con- 
sisting mainly  of  an  operculum  which  has  become  modified  for  acoustic 
purposes"  (Bland-Sutton).  Recognition  of  the  presence  of  tem- 
porary opercula  on  all  the  branchial  arches  explains  the  occasional 
occurrence  of  cervical  auricles  in  man.  Failure  of  coalescence  between 
the  units  which  form  the  ear  explains  the  occurrence  of  various  con- 
genital fistulae  and  tumors  of  the  ear,  while  an  excess  in  the  number  of  the 
primary  tubercles  can  account  for  the  occurrence  of  accessory  lobes  to  the 
ear.  The  growth  of  the  external  ear,  as  described  above,  separates  the 
dorsal  portion  (angular  fossa)  from  the  rest  of  the  first  branchial  cleft. 
This  angular  fossa  becomes  divided  into  two  parts:  one  remaining 
shallow  constitutes  the  concha,  while  the  other  becoming  deep  gives 
rise  to  the  external  auditory  meatus. 

The  edges  of  the  first  branchial  cleft  on  its  visceral  or  endodermic 
side  coalesce  and  so  convert  the  cleft  into  a  canal  which  ultimately  forms 
the  tympanic  cavity  and  the  Eustachian  tube.  The  walls  of  the  tube 
are,  of  course,  formed  by  the  first  and  second  branchial  arches  and  from 
them  are  developed  the  ossicles  with  their  muscles.  From  the  first  arch 
arise  the  malleus  and  incus;  from  the  second  arch  arises  the  ring  of 
the  stapes  (the  plate  of  this  ossicle  is  developed  from  the  fundament 
of  the  internal  ear). 

At  first  the  ossicles  lie  imbedded  in  soft  gelatinous  tissue  outside 
the  tympanic  cavity  which  is  a  narrow  fissure,  but,  after  birth,  air 
passing  up  the  Eustachian  tube  enlarges  the  cavity  and  presses  its 
endodermic  lining  (mucous  membrane)  over  and  between  the  ossicles 
until,  the  gelatinous  tissue  having  shrunk,  the  ossicles  become  appar- 
ently free  in  the  tympanic  cavity.  This  freedom  is  only  apparent  as 
the  ossicles  are  enclosed  in  folds  of  mucous  membrane  and  thus  at- 
tached to  the  walls  of  the  tympanum  in  similar  fashion  to  that  by 
which  the  small  intestine  is  attached  to  the  abdominal  wall. 

During  the  second  month  of  intra-uterine  life  the  eyelids  are  formed. 


DEVELOPMENT  55 

The  lower  lid  is  formed  as  a  fold  from  the  skin  of  the  superior  maxillary 
process,  while  the  upper  is  formed  from  a  fold  of  skin  which  unites  the 
superior  maxillary  process  to  the  frontal  process.  The  inner  angle  of 
both  lids  arises  from  the  external  extremity  of  the  primitive  frontal 
process.  As  the  lids  grow,  their  edges  meet  at  about  the  third  month 
and  become  fused  together.  This  fusion  is  only  epitheUal  and  during 
its  existence  the  Meibomian  glands  and  the  eyelashes  form.  A  few 
days  prior  to  birth  the  eyelids  in  man  separate,  while  in  many  animals, 
e.g.,  dogs,  the  fusion  persists  for  some  days  after  birth. 

The  Meibomian  glands  are  formed  from  the  rete  Malpighii,  the  cells 
of  which  proliferate  and  penetrate  the  eyelid  as  solid  rods  which  later 
become  tubules.  On  the  median  side  of  the  eye  in  many  Animals, 
e.g.,  birds,  a  third  lid  is  formed  under  the  others  and  is  named  the 
memhrana  nictitans.  In  man  this  third  lid  exists  merely  as  a  rudiment 
—the  plica  similunaris — and  a  number  of  small  glands  which  are  de- 
veloped in  it  produce  a  reddish  nodule,  the  canmcula  lachrymalis. 
The  ocular  surface  of  the  eyeUds  gives  rise  to  the  conjunctival  sac  and 
from  the  outer  and  upper  recess  of  this  sac  epithelium  penetrates  the 
deeper  tissues,  upward,  and  forms  soUd  branched  rods  which  later 
become  hollow  and  form  the  lachrymal  gland. 

From  the  inner  angle  of  the  eye  a  cleft  bounded  by  the  frontal 
process  above  and  the  superior  maxillary  process  below  leads  from  the 
eye  to  the  oro-nasal  cavity — the  lachrymal  fissure.  In  the  bottom  of 
this  fissure  a  solid  rod  of  epithelium  forms  and  becomes  buried  in  the 
mesoderm.  This  rod  becomes  hollowed  out  into  a  tube  long  after  it 
has  been  entirely  separated  from  its  ectodermic  origin  and  constitutes 
the  lachrymal  duct.  At  first  the  lachrymal  duct  is  separated  from  the 
nasal  cavity,  but  shortly  before  birth  (sometimes  even  after  birth)  the 
duct  becomes  patent  the  whole  distance  between  the  eye  and  the  nose. 
The  lachrymal  fissure  itself  becomes  completely  obliterated. 


SECTION  V 
HARE-LIP  AND  CLEFT  P.ALATE 

By 
JOHN  FAIRBAIRN  BINNIE,  A.  M.,  C.  M.,  F.  A.  C.  S. 

Hare -lip  is  due  to  a  want  of  union  between  the  superior  maxillary 
process  of  one  side  and  the  fronto-nasal  process.  Most  authorities 
believe  this  failure  of  union  to  be  between  the  superior  maxillary  and 
the  central  part  of  the  fronto-nasal  processes.  Albrecht  thinks  that 
hare-lip  is  occasioned  by  a  failure  of  union  between  the  lateral  portion 
of  the  fronto-nasal  process  which,  in  his  opinion,  takes  part  in  the 
formation  of  the  normal  upper  Hp,  and  the  central  portion  of  the  same 
process  (Fig.  25). 

The  cleft  in  the  lip  may  be  partial  or  complete.  When  complete, 
the  cleft  extends  from  the  margin  of  the  lip  into  the  nostril,  and  the 
corresponding  ala  of  the  nose,  having  lost  its  anchorage  to  the  middle 
line,  is  usually  displaced  laterally  and  adds  considerably  to  the  deform- 
ity. Partial  hare-lip  varies  from  a  mere  notching  of  the  Hp  margin 
to  a  cleft  which  almost  invades  the  nostril.  When  the  superior  maxil- 
lary processes  of  both  sides  fail  to  unite  with  the  fronto-nasal  process, 
double  hare-Up  results.  The  clefts  in  double  hare-hp  may  be  partial  or 
complete,  or  one  may  be  partial  and  the  other  complete.  When  both 
clefts  are  complete,  the  portion  of  tissue  between  them  (the  lunula)  is 
generally  atrophied  or  distorted.  Hare-lip  is  very  frequently  accom- 
panied by  cleft  palate. 

Some  rare  cases  of  hare-lip  have  been  reported  in  w^hich  a  cleft 
exists  involving  the  lip  margin  and  from  the  cleft  to  the  nostril  there 
extends  a  groove  the  floor  of  which  consists  of  skin  and  mucous  mem- 
brane without  any  muscle;  in  other  cases  of  apparently  complete  hare- 
lip a  narrow  bridge  of  tissue  may  span  the  cleft  about  its  middle.  These 
pecuhar  conditions  have  been  attributed  to  intra-uterine  healing,  but 
they  are  really  examples  of  partial  hare-lip. 

Cleft  Palate. — The  palate  is  formed  by  the  union  of  the  palatal 
processes  of  the  superior  maxillary  process  with  the  septum  of  the  nose 
and  the  intermaxillary  bone  (these  two  arising  from  the  fronto-nasal 
process).     If  the  union  between  these  structures  fails  to  be  accom- 

87 


REGIONAL   SURGERY 


Cleft  alveolus 


plished,  the  result  is  a  cleft  palate  which  may  be  single  or  double,  com- 
plete or  incomplete. 

In  single,  complete  cleft  palate  there  is  a  cleft  between  the  superior 
maxillary  process  of  one  side  and  the  bony  and  cartilaginous  derivations 
of  the  fronto-nasal  process.  (According  to  Albrecht's  theory,  the  an- 
terior portion  of  the  cleft  runs  between  the  lateral  and  central  segments 
of  the  intermaxillary  bone  or  the  lateral  segment  of  that  bone  is  absent.) 
In  double,  complete  cleft  palate  there  is  no  union  between  the  various 
components  of  the  palate,  the  result  being  a  double  cleft  through  the 

alveolus  and  a  single  cleft  through  the 
rest  of  the  palate.  When  the  union  be- 
tween the  elements  forming  the  palate 
is  only  partial,  then  an  incomplete  cleft 
palate  results.  (Cleft  alveolus;  cleft  al- 
veolus and  hard  palate;  cleft  uvula;  cleft 
soft  palate;  cleft  of  soft  and  hard  palates; 
^^^       ^"^Vy  fistula  in  hard  or  soft  palates.)     (Figs.  28 

/    y^      ^V   \  ^.    ,  .  ^    ,    and  20.)     The  fact  that  the  various  com- 

l      r  Mil  Fistula  in  hard  ^  ■' 

\j        Q       \j   P^^^^®  ponents  of  the  palate  are  normally  early 

united  exercises  a  strong  restraining  in- 
^\J  fluence  on  the  growth  of  each  component; 

in  fact  the  palate  grows  and  shapes  itself 

^.^-^     "N^  as  a  whole.     When  union  between  these 

/  ^'^'~"*>.  \     Cleft  uvula       parts  docs  not  take  place,  this  restraining 

\^  \j  influence  is  absent  and  each  part  grows 

independently   and   generally  erratically. 
'ijl/^  Thus  in  single  cleft  palate  the  septum 

Fig.  28.'  does  not  remain  in  the  middle  line  but  is 

pulled  over  toward  the  side  on  which  it  is 
attached,  while  the  palatal  bone  on  the  affected  side  is  usually  much 
more  nearly  vertical  than  normal.  In  complete  double  cleft  palate 
the  unattached  intermaxillary  bone  is  borne  forward  by  the  growth  of 
the  nasal  septum  until  it  lies  well  anterior  to  the  normal  hne  of  the 
alveolus  and  occupies  a  position  entirely  analogous  to  the  premaxillary 
bone  of  many  animals  (Figs.  29,  30  and  31).  The  lunula  of  the  upper 
lip  in  such  cases  usually  exists  as  a  tag  of  skin  on  the  top  of  the  inter- 
maxillary bone  projecting  forward  from  the  point  of  the  nose. 

In  single,  complete  cleft  palate  the  alveolus  which  is  attached  to  the 
intermaxillary  bone  usually  grows  out  of  alignment,  protrudes  forward 
and  becomes  unduly  prominent.     The  etiology  of  hare-lip,  cleft  palate 


■\r 


HARE-LIP   AND    CLEFT   PALATE 


89 


and  the  various  facial  clefts  and  deformities  discussed  in  the  suc- 
ceeding pages  is  very  obscure.  It  is  well  known  that  such  deformities 
are  often  hereditary,  but  yet  there  is  very  often  no  such  history.     The 


Fig.  29. 

distressed  mother  frequently  attributes  the  deformity  to  some  "mater- 
nal impression"  or  to  some  accident  sustained  during  the  pregnancy. 
Amniotic  adhesions  have  been  blamed  for  their  occurrence  and  theo- 
retically may  act  in  three  ways: 


Fig. 


Fig. 


1.  The  amniotic  sac  may  be  adherent  to  the  sides  of  the  branchial 
clefts  and  so  prevent  their  normal  closure. 

2.  The  adhesions  may  be  to  the  cheek  of  the  embryo  at  a  distance 


90  REGIONAL   SURGERY 

from  the  cleft  and  act  by  preventing  the  superior  maxillary  process 
growing  inward  to  come  into  contact  with  the  fronto-nasal  process. 

3.  An  adhesion  between  any  part  of  the  embryo  {e.g.,  one  of  the 
limbs)  and  the  sac  may  form  a  string  and  this  string  or  band  may 
cause  such  pressure  on  one-half  of  the  face  as  to  prevent  growth  in 
the  direction  necessary  for  fusion,  or  the  band  may  actually  He  in  the 
embryonal  cleft  and  so  prevent  closure. 

Some  authors  have  considered  that  the  tags  of  skin  and  cartilage 
which  constitute  accessory  auricles  are  really  remnants  of  amniotic 
.  adhesions. 

Many  arguments  pro  and  con  have  been  advanced  but  nothing  has 
been  proved.  (See  F.  Konig,  Berl.  Klin.  Wochenschr.,  1895,  No.  34; 
E.  Fronhofer,  Archiv  fiir  Klin.  Chir.,  LII,  p.  883;  Th.  Haymann,  Archiv 
fiir  Klin.  Chir.,  LXX,  p.  1033.) 

Treatment  of  Hare-lip  and  Cleft  Palate. — The  only  treatment  for 
hare-Up  and  cleft  palate  is  operation,  but  before  undertaking  operation 
it  may  be  necessary  to  prepare  the  child  by  proper  feeding  and  by  the 
treatment  of  adenoids  or  any  such  lesions  which  may  be  present  and 
might  interfere  with  the  healing. 

Principles  underlying  all  good  operations  for  hare-lip: 

1.  Tension  must  be  relieved,  so  that  the  function  of  the  sutures 
is  practically  merely  to  hint  to  the  edges  of  the  cleft  that  they  must 
stay  in  apposition. 

2.  The  edges  of  the  cleft  must  be  freshened  so  that  union  can  take 
place. 

3.  This  freshening  must  be  done  in  such  a  way  that  the  edge  of  the 
upper  lip  opposite  the  line  of  suture  is  made  to  project  below  the 
normal  level  of  the  lip.  The  object  of  this  is  to  avoid  the  occurrence  of 
a  notch  on  the  lip  after  the  wound  has  shrunk  when  healing  is  complete. 

4.  The  freshened  edges  of  the  cleft  must  be  brought  together  and 
kept  together. 

5.  The  red  line  of  the  lip  must  extend  in  a  clean,  unbroken  curve 
from  one  side  of  the  newly  formed  lip  to  the  other. 

6.  The  depth  of  the  mucous  membrane  must  be  equal  on  each  side 
of  the  Hne  of  suture. 

7.  The  newly  formed  lip  must  not  be  too  short,  but  must  be  length- 
ened so  that  it  will  more  than  cover  the 'gums. 

8.  The  nostril  must  be  reproduced  so  as  to  have  exactly  the  same 
dimensions  as  the  sound  nostril,  and  must  consist  of  tissue  of  the  same 
texture  as  the  normal  nostril. 


HARE-LIP   AND    CLEFT   PALATE 


91 


9.  There  must  be  no  flattening  of  the  nose  or  ala  nasi  on  the  afifected 
side. 

Incomplete  Single  Hare-lip. — The  cleft  in  the  Hp  does  not  extend 
into  the  nostril;  it  is  a  mere  notch.  It  may  be  unnecessary  to  relieve 
tension,  though,  when  the  cleft  is  at  all  wide,  this  is  imperative  and  must 
be  done  thoroughly.  Malgaigne's  operation  or  Nelaton's  (Figs.  32,  33, 
34  and  35)  are  very  good.     When  the  ala  of  the  nose  is  pulled  to  the  side 


Fig.  32. 
Figs.  32  and  ^3- — Malgaigne. 


Fig.  S3. 

{Esmarch  and  Kowalzig.) 


Fig.  34. 

Figs.  34  and  35. 


Fig.  35. 

-Nelaton.     {Esmarch  and  Kowalzig.) 


Fig.  36.  Fig.  37. 

Figs.  36  and  37. — C.  H.  Mayo's  operation. 

and  the  nostril  is  much  widened  C.  H.  Mayo  reheves  tension  very 
thoroughly,  separating  the  ala  of  the  nose  from  its  deep  connections; 
then  he  makes  his  denudation  at  the  floor  of  the  nostril  (Fig.  36  A,  B) 
and,  by  pulling  the  lip  downward  and  introducing  sutures,  converts 
the  horizontal  wound  AB  into  a  vertical  one  (Fig.  37).  The  result  is 
obliteration  of  the  notch  in  the  lip  and  correction  of  the  deformed 
position  of  the  ala  of  the  nose. 


92  REGIONAL   SURGERY 

Complete  Single  Hare-lip. — Relief  of  Tension. — This  is  one  of  the 
most  important  steps  in  all  hare-hp  operations.  Failure  to  relieve 
tension  completely  is  the  most  common  cause  of  bad  results.  The 
upper  lip  is  everted  and  pulled  upward  and  outward  by  the  finger  and 
thumb  of  the  left  hand  (Fig.  38).  The  mucous  membrane  is  incised 
at  its  reflection  from  gum  to  lip,  and  divided  from  the  premolar  region 
on  one  side  to  the  premolar  region  on  the  other  side,  if  necessary. 
Through  this  incision,  with  knife  or  scissors,  one  separates  the  soft  parts 
from  the  bones  (keeping  the  instrument  close  to  the  bone).  Particular 
attention  must  be  paid  to  the  separation  of  the  ala  of  the  nose  from  the 
bone  (Fig.  39). 


Fig.  38. — Relief  of  tension.  Fig.  39. 

The  dotted  area  represents  the  extent  of  dissection 
that  is  commonly  required  for  the  rehef  of  tension. 

To  what  extent  must  the  soft  parts  be  separated  from  the  bone? 
The  answer  to  the  foregoing  question  is,  until  the  edges  of  the  cleft 
in  the  lip,  when  placed  together,  show  a  tendency  to  lie  in  apposition, 
so  that  the  sutures  when  introduced  may  be  tied  without  giving  rise  to 
tension. 

Freshening  the  Edge  of  the  Cleft. — The  methods  of  doing  this  are 
legion. 

J.  E.  Thompson's  Methods. — To  insure  accuracy  in  making  the 
incisions  use  sharp-pointed  compasses  which  can  be  fixed  by  a  screw  and 
with  them  make  all  the  necessary  measurements  and  marks. 

I.  There  is  not  much  diversion  of  the  sides  of  the  cleft.  At  A  and 
A',  Fig.  40  (i)  a  projection  or  shoulder  shows  the  junction  of  the  cleft 
and  the  nasal  margin.  With  compasses  measure  the  distance  from  Y 
(midway  between  A  and  A')  to  Z  placed  on  an  imaginary  line  KX  which 
represents  the  natural  curve  of  the  upper  Hp.  Fix  the  compasses  so 
that  their  points  will  remain  this    distance  (YZ)   apart.     Place  one 


HARE-LIP   AXD    CLEFT   PALATE 


93 


94  REGIONAL   SURGERY 

point  of  the  compasses  at  A  and  the  other  at  B  on  the  skin  of  the  lip 
close  to  the  red  line  of  the  mucous  membrane.  Mark  the  point  B, 
Fig.  40  (2)  by  pricking  the  skin.  In  the  same  fashion  find  and  mark  the 
point  B'.  The  line  AB  equals  in  length  the  line  A'B'.  Readjust  the 
compasses  and  take  the  measurement  BC,  the  point  C  being  on  the  free 
margin  of  the  Hp.  The  angle  ABC  is  usually  about  60°  and  must 
always  be  less  than  90°  if  a  projecting  prolabium  is  to  result  from  the 
completed  operation.  Mark  the  point  C  by  pricking  the  mucosa.  In 
the  same  fashion  find  and  mark  the  point  C.  The  line  BC  equals  in 
length  the  line  B'C.  Pass  a  retaining  stitch  of  horsehair  "through 
each  side  of  the  mucous  membrane  of  the  lip  close  to,  but  below,  C  and 
C."     Suture  A  to  A',  B  to  B',  C  to  C  (Fig.  40  (3)). 

2.  The  sides  of  the  cleft  are  unsymmetrical.  Fig.  40  (4)  shows 
how  the  same  operation  gives  the  same  results  provided  the  cheeks 
have  been  well  mobilized. 

Double  Uncomplicated  Hare-Up. — The  deformity  is  not  complicated 
by  the  central  portion  or  lunula  of  the  lip  being  carried  forward  toward 
the  tip  of  the  nose  by  the  intermaxillary  bone. 

J.  E.  Thompson's  method  (Surg.  Gyn.  Obst.,  May,  1912).  In 
Fig.  40  (5)  and  (6)  "the  shoulders  marking  the  margins  of  the 
nostrils  are  shown  at  A  and  E,  and  at  A'  and  E'.  The  triangle  E'DE 
shows  the  line  of  incision  by  which  the  central  piece  of  skin  covering 
the  intermaxillary  bone  is  pared.  E  and  E'  are  placed  on  the  inner 
margins  of  the  nostrils.  The  sides  DE  and  DE'  are  usually  equal  in 
length  to  one  another  and  their  length  varies  according  to  the  depth 
of  the  central  piece  of  skin.  It  must  never  be  greater  than  AB  and  is 
usually  much  less.  The  points  A,  B  and  C  and  A',  B'  and  C  are 
chosen  as  described  previously  in  the  operation  on  single  hare-lip. 
Fig.  40  (6)  shows  the  final  appearance  of  the  lip  when  the  flaps 
have  been  cut  and  the  parts  approximated.  The  point  A  is  in  contact 
with  E,  A'  with  E';  the  apex  D  of  the  triangle  E'DE  Hes  somewhere 
along  the  line  AB;  the  point  B  is  in  contact  with  B',  and  C  with  C, 

Two  essential  points  must  be  emphasized: 

1.  Under  no  circumstances  must  the  circumference  of  the  nostril 
be  encroached  upon.  The  shoulders  that  represent  the  margins  of  the 
nostril  must  be  accurately  approximated. 

2.  The  points  B  and  B'  must  be  as  close  to  the  red  line  of  the  lip  as 
possible,  and  must  always  be  on  the  skin  (upper)  side  of  this  line. 

Complicated  Hare-lip. — Single  complete  hare-lip.  The  alveolus 
is  cleft  and  one  side  of  the  cleft  is  much  more  prominent  than  the  other 


HARE-LIP   AND    CLEFT   PALATE 


95 


If  possible  push  the  protruding  part  into  alignment  with  the  rest  of  the 
alveolus.  If  this  is  not  possible  introduce  a  mattress  suture  of  wire  as 
shown  in  Fig.  41.  Divide  the  alveolus  at  A,  push  the  mobilized  portion 
of  bone  into  proper  position  and  fasten  it  with  the  wire. 

Complicated  Double  Hare-lip. — The  intermaxillary  bone  is  situated 
at  the  tip  of  the  nose. 

Some  surgeons  advise  removal  of  the  misplaced  intermaxillary  bone 
but  this  is  entirely  improper.  It  ought  to  be  re- 
placed in  the  alveolar  cleft.  Most  of  the  methods 
of  operating  cause  so  much  deformity  of  the  nasal 
septum  that  the  passages  are  seriously  occluded 
and  a  "blunt  and  bull-dog"  nose  is  formed.  Reich 
has  endeavored  to  overcome  these  errors. 

Reich's  Operation. — Step  i . — Dissect  the  phil- 
trum  from  the  intermaxillary  bone  and,  in  doing 
so,  expose  the  edge  of  the  cartilaginous  septum  immediately  above  the 
intermaxillary  bone.  With  straight  scissors  divide  the  nasal  septum 
obliquely  upward  and  backward  as  high  as  possible  (Fig.  42). 
This  cut  divides  the  mucosa,  periosteum  and  perichondrium,  cartilagi- 
nous septum  and  the  perpendicular  plate  of  the  ethmoid  and  leaves 
in  front  of  it  and  separate  from  the  rest  of  the  septum,  a  plate  of  bone 


Fig. 


41. 


Fig.  42.  Fig.  43. 

Figs.  42  and  43. — i.  Point  of  Nose.     2.  Philtrum  of  nose.     3.  Intermaxillary  bone. 
4.  Oblique  section  of  septum.     5.  Wedge  of  septum  removed. 


and  cartilage  reaching  from  the  root  to  the  tip  of  the  nose,  guarantee- 
ing its  profile. 

Step  2. — Make  an  incision  about  ^^  inch  in  length  through  the 
muco-periosteum  of  the  posterior  portion  of  the  nasal  septum.  Pass 
a  fine  periosteal  elevator  through  this  incision  and  raise  the  muco-peri- 
osteum on  each  side  of  the  septum.     With  strong  scissors  excise  a  tri- 


96  REGIONAL   SURGERY 

angular  piece  of  the  septum.  Push  the  intermaxillary  bone  into  correct 
position. 

Step  3. — Close  the  hare-lip  in  the  usual  manner,  using  the  philtrum 
nasi  to  form  the  cutaneous  septum  of  the  nose  (Fig.  43), 

Sutures  in  Operations  for  Hare-lip. — One  or  two  deep  sutures  in- 
volving almost  the  whole  thickness  of  the  lip  must  be  inserted.  The 
best  material  for  these  is  silkworm-gut  or  waxed  silk.  Hare-lip  pins 
have  been  discarded,  as  they  cause  too  much  scarring.  Usually  the 
deep  sutures  are  inserted  through  the  skin  and  give  rise  to  considerable 
scarring  at  their  points  of  entrance  and  emergence;  a  better  plan  is  to 
introduce  the  deep  sutures  from  the  mucous  surface  and  not  to  involve 
the  skin  in  their  bite;  when  this  is  done,  these  stitches  must  not  be 
removed  until  healing  is  complete,  when  they  will  generally  be  found  to 
have  cut  their  own  way  out.  If  the  surgeon  endeavors  to  remove  such 
sutures  at  the  end  of  a  week,  he  requires  to  evert  the  lip,  and  thus  jeop- 
ardizes the  line  of  union.  Several  superficial  cutaneous  sutures  must  be 
introduced;  the  best  material  for  these  is  horsehair.  Horsehair 
sutures,  because  of  their  elasticity,  leave  less  scar  than  any  others.  All 
cutaneous  sutures  (superficial  and  deep)  may  be  removed  by  the 
seventh  day.  It  is  wise  to  remove  a  few  of  the  superficial  sutures  as 
early  as  the  second  day. 

Dressings  after  Operations  for  Hare-lip. — Should  tension  on  the 
sutures  be  feared,  a  strip  of  adhesive  plaster  may  be  placed  from  cheek  to 
cheek  across  the  upper  lip,  in  such  a  way  as  to  relieve  tension.  If, 
however,  the  soft  parts  of  the  lip  and  cheeks  have  been  sufficiently 
separated  from  the  bones  at  the  beginning  of  the  operation,  such  a 
measure  is  unnecessary  and  undesirable,  as  it  simply  irritates  the 
already  irritated  patient.  It  is  not  necessary  to  apply  any  dressing  to 
the  wound,  as  nature  soon  seals  it  with  dried  blood-clot.  Until  the 
sutures  are  removed  there  should  be  as  little  interference  with  the 
wound  as  possible.  If  it  is  going  to  heal,  it  will  heal  under  the  scab,  and 
the  best  intentioned  endeavors  to  clean  the  wound  will  merely  interfere 
with  nature's  work  and  do  no  good,  as  cleanliness  can  never  be  attained 
in  such  cases. 

Care  must  be  taken  to  so  fix  the  little  patient's  arms  that  scratching 
of  the  wound  is  rendered  impossible. 

Treatment  of  Cleft  Palate. — The  best  time  to  operate  for  cleft  palate 
is  before  the  eruption  of  the  milk  teeth. 

Rose's  or  Trendelenburg's  position  is  of  much  advantage  in  prevent- 
ing blood  from  entering  into  the  larynx  and  trachea. 


HARE-LIP   ANT)    CLEFT   PALATE 


97 


For  swabbing  the  mouth  fragments  of  marine  sponges  are  preferable 
to  pledgets  of  gauze.  A  good  light  is  essential.  The  anaesthetic  ought 
to  be  administered  by  means  of  a  vaporizer  through  a  catheter-like  tube 
so  that  continuous  anaesthesia  may  be  maintained 
without  interfering  with  the  operation. 

Brophy's  Operation. — Applicable  in  children 
younger  than  three  months;  generally  possible, 
though  not  so  easy,  in  children  up  to,  but  not  be- 
yond, the  sLxth  month.  The  only  special  instru- 
ments required  are  two  of  Brophy's  strong  needles 
(Fig.  44);  a  few  strands  of  No.  20  silver  wire;  lead 
plates  No.  17,  American  gage.  No  special  mouth- 
gag  is  necessary,  the  assistant's  fingers  being  suffi- 
cient to  keep  the  mouth  open  and  the  tongue  de- 
pressed. During  operation  bleeding  is  easily  con- 
trolled by  pressure  with  sponges  wrung  out  of  hot 
water. 

The  Operation. — i.  Anaesthetize  the  patient. 
Place  in  Rose's  or  Trendelenburg's  position.  Pass 
a  stout  thread  through  the  anterior  end  of  the 
tongue    as    a    traction    suture.      This    is    a    great    convenience. 

2.  With  a  knife  pare  thoroughly  the  edges  of  the  cleft  in  the  hard 
palate,  cutting  away  a  little  of  the  bone  itself  to  insure  thoroughness. 


Fig.      44. — (Brophy, 
"Dental  Cosmos") 


Fig.  45. — (Brophy,  "Dental  Cosmos.") 


Either  pare  or  horizontally  spht  the  edges  of  the  cleft  in  the  soft  palate. 
If  split  thoroughly,  the  edges  of  the  spht  retract  and  thus  a  good  raw 
surface  is  left  without  any  loss  of  tissue. 
7 


98 


REGIONAL   SURGERY 


3.  Thread  a  Brophy  needle  with  strong  silk.  Raise  the  cheek  and  pass 
the  threaded  needle  through  the  superior  maxilla  from  without  inward 
at  a  point  just  back  of  the  malar  process  and  high  enough  to  be  above 
the  palate  (Fig.  45).  When  the  needle  appears  in  the  cleft,  pick  up  the 
thread,  which  it  carries,  with  hook  or  forceps.  Withdraw  the  needle, 
leaving  the  loop  of  thread  in  situ.  Catch  the  ends  of  the  thread  in  a 
hemostat.  Through  a  corresponding  part  of  the  opposite  bone  pass  a 
loop  of  thread  in  the  same  manner.  Pass  this  second  loop  of  thread 
through  the  first  and  pull  the  latter  out,  carrying  with  it  the  former. 
We  now  have  a  loop  of  thread  passing  through  both  superior  maxillary 
bones  above  the  palate,  and  when  necessary  through  the  nasal  septum. 
By  means  of  this  thread  pull  a  strand  of  very  strong  silver  wire  through 
the  same  track. 

4.  In  the  same  manner  introduce  one  or  sometimes  two  other  silver 
wires  through  the  anterior  portion  of  the  maxilla  above  the  level  of  the 

palate. 

5.  Pass  the  ends  of  the  silver  wire 
through  the  holes  in  lead  plates  moulded 
to  fit  the  convexity  of  the  buccal  surfaces 
of  the  bones  (one  plate  on  each  side). 
Draw  the  wires  tight  and  twist  them 
together — i.e.,  twist  the  "right  end  of  the 
anterior  wire  to  the  right  end  of  the  pos- 
terior wire  and  do  the  same  on  the  left 
side." 

6.  With  the  thumbs  forcibly  press  the 
two  maxillary  bones  together  until  the  cleft  is  completely  closed. 
Twist   the  wires  once  more  so  as  to  hold  the  bones  firmly  together. 

7.  Close  the  soft  palate  by  sutures.  The  state  of  the  patient  may 
necessitate  this  step  being  delayed  until  another  day.  Do  not  close  the 
hare-]ip  until  the  palate  is  completely  closed  and  the  patient  has 
recovered. 

Lane's  Operation. — Uranoplasty. — For  many  reasons  the  operation 
should  be  performed  as  early  as  possible  after  birth.  Before  the  milk 
teeth  erupt  there  is  plenty  of  material  present  to  permit  the  closure  of 
almost  any  defect  no  matter  how  wide  it  may  be.  The  large  surfaces  of 
bare  bone  left  after  Lane's  operation  heal  very  rapidly. 

Instruments  required: 

I.  Lane's  mouth  gags  with  sharp  teeth  which  bite  into  the  gums. 
These  are  sold  in  pairs  of  proper  sizes  (Fig.  46). 


Fig.  46. — {Lane.) 


HARE-LIP   AND    CLEFT   PALATE 


99 


2.  Lane's  needle  holder  with  very  small  needles  (Fig.  47).     This  was 
originally  devised  for  suture  of  the  bile  ducts. 

3.  One  small,  strong  knife.     A  Jones'  tenotome  will  serve  admirably. 

4.  Fine,  sharp-pointed  scissors. 

5.  One  strong  hemostat  with  mouse  teeth  at  the  point. 

6.  Fine,  strong  silk. 

7.  A  good  mouse-tooth  dissecting  forceps  suitable  for  catching  the 
tissues  or  the  end  of  a  needle. 

Type  A.^ — The  cleft  in  the  hard  palate  is  unilateral. 
The  septum  is  continuous  with  the  hard  palate  on  one 
side.     The  alveolus  and  the  soft  palate  are  also  cleft. 

Step  I. — Formation  of  reflected  flap.  Make  the 
incision  7,  5,  6,  8  through  the  muco-periosteum  to  the 
bone  (Fig.  48).  In  order  to  obtain  plenty  of  tissue 
that  part  of  the  incision  represented  by  the  line  from  5 
to  6  is  made  on  the  outer  surface  of  the  alveolus  near 
the  reflection  of  the  mucosa  from  the  alveolus  to  the 
cheek.  Make  the  incision  through  the  mucosa  of  the 
soft  palate,  but  do  not  injure  the  musculature.  Reflect 
flap  7,  5,  6,  8.  The  pedicle  or  hinge  of  the  flap  corre- 
sponds to  the  edge  of  the  cleft  in  the  palate. 

In  separating  the  muco-periosteum  from  the  bone 
as  the  posterior  palatine  foramen  is  approached,  an 
elevator  pressed  in  between  the  flap  and  the  bony  palate 
causes  the  posterior  palatine  vessels  and  nerves  to  pro- 
trude for  a  considerable  length  in  a  tube  of  periosteum. 
This  is  readily  grasped  by  an  efficient  hemostat,  which 
is  left  in  place  until  hemostasis  is  assured. 

That  portion  of  the  flap  taken  from  the  soft  palate 
consists  of  mucosa  and  submucosa.     It  is  important 
not  to  injure  the  muscles  of  the  palate.     The  reflected  flap  is  formed  on 
the  side  of  the  cleft  which  is  not  attached  to  the  septum. 

Step  2. — On  the  side  of  the  cleft  attached  to  the  septum  proceed  as 
follows:  With  forceps  pull  the  uvula  and  soft  palate  forward  so  as  to 
expose  the  nasal  surface.  Divide  the  mucosa  along  the  posterior  edge 
of  the  soft  palate  (4,  3,  Fig.  48).  Continue  the  incision  across  the  nasal 
surface  of  the  soft  palate  to  the  point  where  the  soft  and  hard  palates 
meet  at  the  edge  of  the  cleft  iz,^)-  Continue  the  incision  forward  along 
the  edge  of  the  hard  palate  (2,  i)  and  across  the  alveolus  (i,  9).  The  part 
of  the  incision  affecting  the  hard  palate  and  the  alveolus  penetrates  the 


Fig.  47. — [Lane.) 


lOO 


REGIONAL   SURGERY 


whole   thickness  of  the  muco-periosteum.     The  part  of  the  incision 
affecting  the  soft  palate  penetrates  only  the  mucosa  and  submucosa. 


Fig.  48. — Lane's  uranoplasty. 

Reflect  the  mucous  flap  (2,3,4)  outlined  on  the  nasal  surface  of  the  soft 
palate.     Introduce  an  elevator  through  the  incision  9,  i,  2  and  separate 


Fig.  49. — Lane's  uranoplasty. 

the  muco-periosteum  from  the  hard  palate  and  to  a  slight  extent  from 
the  alveolus  near  the  point  9.     Divide  the  attachments  of  the  soft 


HARE-LIP    AND    CLEFT    PALATE 


lOI 


palate  to  the  hard  palate  along  the  posterior  edge  of  the  latter,  leaving 
intact  the  mucosa  on  the  oral  side  of  the  palate.  During  step  2  the 
posterior  palatine  artery  remains  uninjured. 

Step  3. — Turn  the  flap  5,7,8,  6,  so  that  its  epithelial-covered  surface 
is  directed  toward  the  nose  and  its  raw  surface  toward  the  mouth. 


Fig.  50. — Lane's  uranoplasty. 

Tuck  the  edge  of  flap  5,  7,  8,  6  well  under  flap  9,  i,  2,  3,  4  and  fix  it  in 
position  by  two  rows  of  line  sutures  (Figs.  49  and  50). 

Type  B  . — The  cleft  is  wide ;  the  septum  is  not  attached  to  the  palate ; 
the  alveolus  is  not  cleft. 

Step  I. — Make  the  flap  i,  2,  3  (Fig.  51)  as  in  type  A. 


FfG.  51. — {Lane.) 

Step  2. — On  the  opposite  side  make  the  incision  6  through  the  muco- 
periosteum  along  the  edge  of  the  cleft.  Make  the  incision  7  and  8  on 
the  nasal  surface  of  the  soft  palate  and  reflect  a  flap  of  mucosa  from  the 
soft  palate  as  in  type  A.  Separate  the  muco-periosteum  from  the  hard 
palate  and  divide  the  attachments  of  the  soft  to  the  hard  palate  along 


102 


REGIONAL   SURGERY 


the  posterior  edge  of  the  latter,  leaving  intact  the  mucous  membrane  on 
the  oral  surface. 

Step  3. — Turn  flap  i,  2,  3  over,  with  its  epithelial  surface  directed 
toward  the  nasal  cavity,  so  as  to  cover  the  cleft.  . 

Tuck  the  free  edge  of  this  flap  well  under  the  flap  10,  6,  7,  8.  The 
triangular  portion  of  this  latter  flap,  which  was  obtained  from  the  nasal 
surface  of  the  soft  palate,  assists  greatly  in  providing  a  thick  new  velum 
palati. 

Step  4. — Suture  the  edge  of  flap  i,  2,  3  to  the  base  of  flap  10,  6,  7,  8 
(Fig.  52).  Suture  the  edge  of  flap  10,  6,  7,  8  to  the  raw  surface  of  flap 
I,  2,3  (Fig.  52). 


Fig.  52. — {Lane.) 

After  the  milk  teeth  have  erupted  some  modification  of  Lane's 
methods  or  the  classical  operation  of  Langenbeck  may  be  selected. 

Langenbeck's  Operation. — Pass  a  thread  through  the  tongue  for 
purposes  of  traction.  Introduce  an  efficient  mouth  gag  (Whitehead's, 
Lane's,  a  wedge  of  wood). 

I.  Denudation. — Seize  the  end  of  the  uvula  on  one  side  with  a 
sharp  hook  or  forceps  (Fig.  53).  With  a  sharp  knife  or  tenotome 
remove  a  strip  of  mucous  membrane  from  the  whole  edge  of  the  cleft. 
In  cutting,  do  so  obliquely,  removing  rather  more  membrane  from  the 
oral  than  from  the  nasal  side  of  the  palate.     This  gives  a  more  extensive 


HARE-LIP    AND    CLEFT    PALATE 


103 


raw  surface,  which  is  a  great  advantage.     When  the  soft  palate  is  very 
thick,  its  edge  may  be  split  instead  of  pared. 

2.  With  a  suitable  periosteotome  or  knife  divide  the  muco-perios- 
teum  along  the  edge  of  the  cleft  in  the  hard  palate.  Separate  all  the 
muco-periosteum  from  the  hard  palate  up  to  the  alveolus  (Fig.  54). 
For  this  procedure  Brophy's  periosteotomes  are  convenient,  but  a  suit- 
able instrument  is  easily  extemporized  from  a  dental  spatula  or  even  an 
aneurism  needle. 

3.  The  soft  palate  may  be  said  to  consist  of  three  layers:  (a) 
The  nasal  mucous  membrane;  (b)  the  tissues  attached  to  the  posterior 


Fig.  53. 

edge  of  the  hard  palate;  (c)  the  oral  mucous  membrane.  Leaving 
intact  the  oral  mucous  membrane,  which  is  continuous  from  hard  to  soft 
palate,  divide  transversely  with  fine  curved  scissors  both  the  nasal 
mucous  membrane  and  the  tissues  attached  to  the  posterior  edge  of  the 
hard  palate.  This  is  one  of  the  most  important  steps  in  the  operation, 
allowing  the  muco-periosteal  flap  obtained  from  the  hard  palate  to  drop 
toward  the  mouth,  and  with  it  the  soft  palate  (Fig.  55). 

Repeat  this  procedure  on  the  opposite  side.     Commonly  the  raw 
edges  of  the  flaps  thus  obtained  will  come  into  apposition  without 


I04 


REGIONAL    SURGERY 


tension.  If  they  do  not,  it  is  necessary  to  make  a  lateral  incision 
through  the  muco-periosteum  parallel  and  close  to  the  alveolus  on  one 
or  both  sides  of  the  mouth,  and  extending  from  the  lateral  incisor  back 
to  the  posterior  margin  of  the  hard  palate.  If  this  is  insufficient  to 
relieve  tension,  Billroth's  procedure  may  be  adopted 
as  follows:  pass  a  fine  chisel  through  the  posterior 
angle  of  the  lateral  incision;  direct  it  obliquely  inward 
and  upward  against  the  hamular  process,  and  with  a 
fight  blow  from  the  hand  make  it  divide  that  bone. 
The  dislocation  of  the  hamular  process,  increased  if 
necessary  by  the  use  of  an  elevator,  gives  perfect  re- 
laxation of  the  velum  palati  and  does  not  injure  its  mus- 
culature. Incisions  through  the  soft  palate  dividing  its 
muscles  were  formerly  considered  necessary;  now  they  are  never 
admissible. 

C.  H.  Mayo  considers  it  important  to  make  lateral  incisions  (Fig.  56) 
on  both  sides,  not  merely  to  reheve  tension,  but  to  permit  the  use  of  a 


Fig.  54. 


Fig.  55. 

N.  M.  Nasal  mucosa.    H.  P.  Hard  palate.    O.  M.  Oral  mucosa.    S.  P.  Soft  palate.    S.  Line  of  section. 

relaxation  tape.  Having  prepared  the  parts  for  the  insertion  of  sutures, 
and  having  made  two  lateral  incisions  close  to  the  alveoli,  he  introduces  a 
narrow  tape  which  surrounds  the  right  and  left  muco-periosteal  flaps. 
Traction  on  the  ends  of  the  tape  brings  the  flaps  toward  the  operator, 


Fig.  56. 


Fig.  57. 


steadies  them,  and  facifitates  the  introduction  of  the  ordinary  sutures. 
When  the  sutures  are  in  place  and  tied,  Mayo  crosses  the  free  ends  of 
the  tape  and  fixes  them  by  tying  a  figature  around  them  at  this  point 
(Fig.  57),  cuts  off  the  superfluous  portions  of  the  tape,  and  lastly  slides 
the  whole  tape  until  that  part  fastened  by  the  ligature  lies  in  the  nasal 
instead  of  in  the  oral  cavity.  The  tape  fastened  as  above  acts  as  an 
efficient  relaxation  suture  or  support;  it  also  drains  secretions  from  the 


HARE-LIP    AND    CLEFT    PALATE 


105 


nasal  cavity  into  the  mouth.     It  is  remarkable  how  this  very  simple 
contrivance  facilitates  the  operation. 

4.  Sutures. — Many  special  needles  have  been  devised  to  overcome  the 
difficulties  met  with  in  closing  palatal  defects.  Of  these,  Deschamp's 
(Fig.  58)  is  perhaps  the  best,  although  it  is  usually  made  too  large. 
The  writer  finds  that  he  can  discard  such  special  instruments  by  using 
very  small,  full-curved  needles,  grasped  in  a  long-necked  needleholder, 


Fig.  58. 

and  passing  each  end  of  the  thread,  armed  with  a  needle,  from  the  nasal 
to  the  oral  side  of  the  palate,  i.e.,  from  within  outward.  The  usual 
method  of  suturing  is  to  begin  at  the  uvula  and  work  forward,  being 
careful  to  evert  the  edges  of  the  wound  when  the  flaps  from  the  hard 
palate  are  being  united.     Silk  or  celluloid  hemp  are  the  materials  used. 

After-treatment. — ^Liquid  or  soft  food  is  alone 
permissible.  Antiseptic  sprays  may  be  used  if 
not  annoying  to  the  patient.  The  patient  should 
get  out  of  bed  and,  in  suitable  weather,  out  of 
doors  as  soon  as  possible.  The  sutures  must  not 
be  removed  earlier  than  the  seventh  day  after 
operation. 

Partial  Cleft  Palate. — When  there  is  a  cleft 
of  the  soft  palate  alone  and   the  edges  can  be 


Fig.  59. 


Z  and  Q.  Line  of  separation 

brought  together  without  tension,  one  is  content  hlrf paL^t?.^  x!  v'/z.^'a  Area 

in  which  muco-periosteum 
(continuous  with  the  velum)  is 
separated  from  the  bone. 


to  pare  the  edges  and  apply  sutures.     When  the 

cleft  in  the  soft  palate  reaches  close  to  the  hard 

or  when  the  latter  is  partially  cleft,  it  is  absolutely  necessary  to  relieve 

tension.     This  is  done  in  the  same  fashion  as  in  complete  cleft  palate, 

by  dividing  the  attachments  of  the  velum  to  the  hard  palate  and  by 

separating  the  muco-periosteum  from  the  bone  to  as  great  an  extent  as 

may  be  necessary  Fig.  59). 

Lane's  Operation. — Type  C. — Wide  cleft  of  soft  palate. 

Step  I. — Reflect  the  flap  i,  5,  6,  7,  8  (Fig.  60)  with  its  base  at  the 
edge  of  the  cleft. 

This  flap  consists  partly  of  muco-periosteum  from  the  hard  palate 
and  alveolus  and  mostly  of  mucous  membrane  from  the  soft  palate  and 
cheek.  The  flap  must  be  large  enough  to  easily  cover  the  defect.  Do 
not  injure  the  musculature  of  the  soft  palate. 


io6 


REGIONAL    SURGERY 


Step  2. — From  the  nasal  surface  of  the  soft  palate  on  the  opposite 
side  of  the  cleft  reflect  the  flap  i,  2,  3,  4  with  its  base  at  the  edge  of  the 
cleft. 


Fig.  60. — [Lane.) 


Fig.  61. — {Lane.) 

Step  3. — Suture  the  two  flaps  together,  one  over  the  other  in  an  over- 
lapping fashion  (Fig.  61). 


SECTION  VI 
CONGENITAL  DEFECTS 

By 
JOHN  FAIRBAIRN  BINNIE,  A.  M.,  C.  M.,  F.  A.  C.  S. 

Congenital  Deformities  of  the  Nose  and  Face  Other  than  Hare-Up. 

— The  lines  of  fusion  shown  diagrammatically  in  Fig.  25,  page  81,  give  a 

hint  as  to  the  many  deformities  which  may  result  from  faulty  coalescence. 

I.  The  internal  nasal  processes  may  fail  to  perfectly  fuse  one  with 

the  other.     The  notch-like  dimple  seen  at  the  point  of  many  handsome 


>.^ 


Fig.  62. — Median  fissure  of  nose.     {Nasse.  v  Bergmann's  Clinic.) 

noses  is  a  mark  of  fusion  which  almost  failed  to  be  complete.  Between 
mere  dimpling  and  the  extensive  fissures  shown  in  Figs.  62  and  63,  all 
degrees  of  deformity  may  be  found. 

When  the  failure  in  fusion  is  confined  to  the  lowest  part  of  the  inter- 
nal nasal  processes  median  hare-lip  results  (Fig.  64) ;  or  there  may  be  a 

107 


io8 


REGIONAL    SURGERY 


cleft  through  the  intermaxillary  bone.  Imperfect  development  of  the 
internal  nasal  processes  may  result  in  absence  of  the  intermaxillary 
bone. 


Fig.  63. — Median  fissure  of  face.     {Bougon  and  Derocque  Rev.  d'Orthop,  1908.) 

Instead  of  fissures  and  dimples  incomplete  fusion  may  give  rise  to 
sinuses  opening  on  the  skin  and  passing  upward  in  the  median  line. 
These  sinuses  are  lined  with  epithelium  and  from  them  hairs  may  pro- 
trude (Fig.  65).  A  sinus  such  as  has  been  de- 
scribed may  exist  without  any  external  opening 
and  give  rise  to  a  dermoid  cyst.  Dermoids  exist- 
ing at  the  root  of  the  nose  have  a  different  origin, 
being  derived  from  the  anterior  end  of  the  medul- 
lary groove  of  the  embryo. 

2.  The  external  nasal  process  may  fail  to  per- 
fectly fuse  with  the  internal  process  and  so  give 
rise  to  lateral  clefts  or  fissures  of  the  nose  (Fig. 
66). 
3.  The  superior  maxillary  process  may  fail  to 
perfectly  fuse  with  the  external  nasal  process.  From  this  failure  a 
cleft  may  extend  from  the -outer  canthus  of  the  eye  outward  and  up- 
ward, or  a  dermoid  may  form  there.  Clefts  of  the  cheek  usually  in- 
volve the  middle  of  the  lower  eyelid  and  the  upper  lip  external  to  the 
outer  edge  of  the  lunula  (Fig.  67).     It  is  this  course  of  clefts  of  the 


Fig.  64. — Median  hare 
lip.      {Ransohoff.) 


CONGENITAL  DEFECTS 


109 


cheek  which  presents  the  strongest  evidence  in  favor  of  Albrecht's 
views  on  development  (page  80).  In  this  deformity  the  eye  is  often 
badly  developed  or  even  absent. 


Fig.  65. — {Bland  Snltofi.)         FiG.  66. — Lateral  cleft  of  nose.     (v.  Bergmann.) 


Fig.  67. — {From  Clioyce's  System  of  Surgery,  Vol.  2,  Cassell  &'  Co.) 

Imperfect  closure  of  the  nasomaxillary  lissure  may  give  rise  to  der- 
moid cysts  or  to  fistulae  at  any  point  on  its  course. 


no 


REGIONAL   SURGERY 


4.  The  superior  maxillary  processes  may  fail  to  unite  with  the  rest 
of  the  first  branchial  arch  (the  mandible)  or  may  unite  with  them  too 
completely. 

Bilateral  failure  of  union  may  give  rise  to  a  symmetrical  but  inor- 
dinately large  mouth.  Unilateral  failure  produces  a  lateral  cleft — 
macrostoma  (Figs.  68  and  69).  Fistulae  or  dermoids  may  result  from 
imperfect  closure  of  the  fissure.     Frequently  tags  of  skin  grow  as  tumors 


Fig. 


-Macrostoma  with  accessory  auricles. 


along  the  line  of  the  fissure  and  are  known  as  mandibular  tubercles. 
Accessory  auricles  not  infrequently  accompany  macrostoma  (Figs.  68 
and  69).  When  fusion  is  too  complete  the  mouth  is  too  small — micro- 
stoma. 

Treatment  of  Macrostoma  and  Microstoma. — The  treatment  of 
macrostoma  is  almost  identical  with  that  for  hare-lip.  1 

When  microstoma  is  of  such  a  degree  as  to  be  a  deformity,  a  plastic 
operation  along  the  following  lines  is  advisable. 

From  the  angle  of  the  mouth  make  an  incision  outward  through  the 


CONGENITAL   DEFECTS 


III 


skin  down  to  but  not  involving  the  mucosa.  The  length  of  the  incision 
corresponds  to  the  size  of  mouth  desired.  Divide  the  mucosa  to 
a  point  about  %  inch  internal  to  the  outer  end  of  the  skin  incision;  at 
this  point  bifurcate  the  mucosal  incision  so  as  to  form  a  triangular  flap 
(with  its  pedicle  external)  of  mucosa;  bring  the  flap  forward  and  suture 
it  to  the  skin  so  that  it  forms  a  mucosal  covering  to  the  angle  of  the  new 
mouth.  Suture  the  mucosa  to  the  skin  along  the  whole  line  of  incision. 
Do  the  same  on  the  opposite  side  of  the  mouth. 


Fig.  69. — Macrostoma  with  accessory  auricles. 

5.  The  mandibular  process  (I  Branchial  Arch)  may  fail  to  unite  com- 
pletely with  its  fellow  on  the  opposite  side.  The  result  of  this  might  be 
a  complete  or  an  incomplete  (Fig.  67)  cleft,  a  fistula  or  a  dermoid.  The 
dimple  so  commonly  seen  on  chins  is  a  hint  that  its  possessor  might 
have  been  the  subject  of  a  serious  deformity.^- 

^  Stieda  (Archiv  fur  Klin.  Chir.,  LXXIX,  Hft.  4)  states  that  the  branchial  arches  are  not 
paired  structures,  e.g.,  the  first  arch  is  a  complete  hoop  going  from  one  side  of  the  body  to 
the  other.  If  this  view  is  correct,  then  median  fissures  and  fistulae  of  the  lower  lip  and  jaw 
must  be  due  to  a  want  of  growth  of  the  arch  in  the  middle  line.     The  various  degrees  of 


112 


REGIONAL   SURGERY 


"In  children  with  double  hare-lip  two  sinuses  are  sometimes  seen 
in  the  mucous  membrane  of  the  lower  lip.  Their  orifices  are  indicated 
by  small  but  prominent  papillee.  The  sinuses  are  large  enough  to  admit 
a  probe,  and  they  are  in  some  instances  2  cm.  deep.  *  *  *  *  These 
sinuses  are  probably  due  to  faulty  coalescence  of  the  intermandibular 
fissure"   (Bland-Sutton). 

Fissures  of  the  lower  lip  and  of  the  lower  jaw  are  exceedingly  rare. 
Deformities  of  the  External  Ear. — In  the  chapter  on  embryology  it 
was  shown  that  the  external  meatus  is  a  remnant  of  the  first  branchial 

cleft  and  that  the  pinna  is  formed  by  the 
fusion  of  various  buds  of  tissue  which 
Bland-Satton  compares  to  the  opercula 
in  sharks. 

Too  complete  fusion  of  the  first  bran- 
chial cleft  may  prevent  the  formation  of 
the  external  auditory  meatus  and  the 
tympanic  cavity;  incomplete  fusion  of 
the  buds  of  tissue,  which  ought  to  form 
the  pinna,  may  leave  that  organ  repre- 
sented merely  by  some  tags  of  skin. 

Figure  70  shows  such  a  rudimentary 
ear,  the  external  auditory  meatus  was  ab- 
sent and  the  man  was  entirely  deaf. 
Slight  errors  in  fusion  of  the  rudiments  of 
the  ear  give  rise  to  fistulas  and  to  der- 
moids. Fig.  71  represents  a  boy  with  a 
fistula  in  each  ear  i  cm.  deep.  Among 
five  members  of  the  patient's  family,  three 
had  auricular  fistulse.  In  the  photograph  a  salivary  fistula,  the  "result 
of  phlegmon,  is  seen  but  has  no  connection  with  the  fistula. 

Maldevelopment  of  any  of  the  buds  going  to  form  the  ear  may  lead  to 
much  deformity. 

Bland-Sutton's  remarks  on  the  presence  of  opercula  on  the  branchial 
arches  (p.  84)  explains  the  occurrence  of  accessory  auricles  along  the 
lines  of  the  branchial  clefts  (Fig.  69).  These  auricles  occasionally 
appear  on  the  neck  and  consist  of  tags  of  skin  often  containing  cartilage. 
Branchial  Cysts  and  Fistulae. — It  has  been  shown  in  the  chapter  on 
embryology  that  the  third  and  fourth  branchial  arches  become  hidden 

fissure  and  of  fistula  formation  are  explained  by  subsequent  greater  or  less  median  fusion 
of  the  developed  lateral  parts  of  the  arch. 


Fig.  70. — Rudimentary  auricles. 


CONGENITAL  DEFECTS 


"3 


in  an  irregular  cavity,  the  precervical  sinus,  the  anterior  wall  of  which 
consists  of  the  operculum.  Normally  the  precervical  sinus  disappears 
and  fusion  between  the  branchial  arches  is  complete. 

Failure  of  complete  obliteration  of  the  precervical  sinus  and  of 
the  branchial  clefts  gives  rise  to  lateral  cysts  and  UstulcB  of  the  neck. 

There  are  four  forms  in  which  branchial  clefts  may  persist- 

1.  Complete  fistula,  usually  involving  the  second  cleft. 

2.  The  external  or  ectodermic  portion  of  the  cleft  persists. 

3.  The  internal  or  endodermic  portion  persists. 


Fig.  71. — Fistula  in  external  ear. 


4.  Both  the  internal  and  external  orifices  disappear  but  an  inter- 
mediate portion  persists.  This  last  form  may  give  rise  to  cysts  or  even 
provide  the  epitheUal  elements  for  a  subsequent  carcinoma. 

When  the  fistula  is  of  the  second  cleft  its  inner  orifice  is  in  the  ton- 
sillar recess.  Some  pharyngeal  diverticulae  are  very  probably  examples 
of  blind  internal  fistulas  of  the  second  branchial  cleft.  Fritz  Konig 
(Archiv  fiir  Klin.  Chir.,  LI,  p.  594)  reports  a  fistula  of  the  second  cleft; 
the  upper  opening  was  in  the  external  ear  between  the  tragus  and  anti- 
tragus,  the  lower  a  short  distance  below  the  angle  of  the  jaw.  Fistulae 
8 


114  REGIONAL    SURGERY 

of  clefts  other  than  the  second  are  very  rare.  The  same  surgeon  saw 
one  of  the  third  cleft,  the  inner  orifice  being  in  the  larynx. 

The  external  openings  of  almost  all  congenital  fistulae  of  the  neck  are 
due  to  failure  in  obliteration  of  the  precervical  sinus  and  are  thus  situated 
internal  to  the  anterior  margin  of  the  sterno-mastoid  muscles.  The 
external  orifices  may  be  at  any  level  in  the  neck  helow  the  digastric 
muscles. 

A  branchial  cyst  may  increase  in  size,  become  infected  and  dis- 
charge its  contents  internally  or  externally  and  so  give  rise  to  a  blind 
internal  or  blind  external  fistula.  In  the  same  manner  (theoretically 
at  least)  a  blind  internal  fistula  may  open  externally  and  become 
complete. 

An  internal  fistula  being  of  endodermic  origin  is  lined  by  mucous 
membrane  and  in  its  walls  lymphoid  tissue  is  commonly  present.  An 
external  fistula  is  of  ectodermic  origin  and  thus  is  lined  by  epidermis  with 
its  derivatives  and  so  may  contain  hair,  sebaceous  material,  etc. 

A  complete  fistula  is  lined  by  epiderm  externally  and  mucous  mem- 
brane internally. 

A  branchial  cyst  may  be  epidermal  or  mucous  according  to  whether 
it  originates  from  the  pharyngeal  or  from  the  external  part  of  a  cleft. 

Branchial  fistulae  are  frequently  bilateral  and  certain  families  seem 
to  have  a  predisposition  toward  them. 

The  orifices  of  the  fistulae  vary  in  size,  being  usually  so  small  as  to 
barely  admit  a  bristle.  The  external  orifice  may  be  indicated  by  a  tag 
of  skin  containing  a  piece  of  yellow  elastic  cartilage  and  forming  a 
cervical  auricle  (Bland-Sutton).  Cervical  auricles  may  be  present  in 
the  neck  without  any  other  deformity,  just  as  similar  accessory  auricles 
may  be  found  on  the  cheek  with  or  without  macrostoma. 

Treatment  of  Branchial  Cysts  and  Fistula. — The  only  true  treat- 
ment of  branchial  cysts  and  fistulae  is  by  excision.  Many  fistulae  give 
little  or  no  annoyance  and  require  no  treatment;  others  are  deforming  or 
give  vent  to  an  annoying  discharge.  Often  fistulae  become  inflamed, 
causing  pain  and  much  trouble  which  cannot  be  cured  without  removal 
of  the  whole  tract. 

Partial  excision  of  a  fistula  is  usually  followed  by  recurrence.  For 
the  excision  of  a  complete  fistula  the  skin  incision  must  be  large  and  the 
whole  fistula  must  be  dissected  free  from  its  surroundings  until  it  hangs 
like  an  appendix  from  its  pharyngeal  connections.  The  rriost  difficult 
part  of  the  operation  is  the  dissection  near  the  pharynx  and  the  closure 
of  the  pharyngeal  wound.     Fritz  Konig  has  avoided  some  of  these 


CONGENITAL  DEFECTS  II5 

difl&culties  as  follows:  After  mobilizing  the  fistula  to  a  point  near  the 
pharynx  (behind  the  tonsil),  open  the  mouth  with  a  suitable  gag;  pass 
an  eyed  probe  from  the  wound  into  the  mouth  through  a  small  incision 
anterior  to  the  tonsil  and  by  its  means  pull  a  thread  into  the  mouth. 
Tie  the  end  of  the  thread  to  the  mobilized  fistula  and  pull  the  latter 
through  the  wound  into  the  mouth;  cut  away  the  excess  of  the  fistula 
and  suture  its  stump  to  the  oral  mucosa.  Close  the  external  wound. 
Instead  of  a  long  fistula  leading  from  the  pharynx  to  the  neck  there  is 
left  a  short  harmless  passage  leading  from  the  back  to  the  front  of  the 
tonsil. 

Median  Cysts  and  Fistulae  of  the  Neck. — It  was  shown  in  the  chapter 
on  embryology  that  the  tongue  is  developed  from  three  buds  and  that 
an  endoderm-lined  canal  (the  thyreo-glossal  duct)  exists  at  the  point 
where  these  three  buds  come  together;  the  lower  part  of  this  canal  forms 
the  median  part  of  the  thyroid.  The  body  of  the  hyoid  bone  (part  of  the 
3rd  branchial  arch)  is  naturally  closely  connected  with  the  thyreo-glossal 
duct;  in  fact  the  bone  may  be  perforated  by  the  duct.  Normally  the 
thyreo-glossal  duct  disappears,  but  it  may  either  remain  more  or  less  pat- 
ent or  its  epithelial  elements  may  proliferate.  The  epithelium  being  of 
the  same  origin  as  the  thyroid,  it  follows  that  when  it  has  proliferated  the 
resulting  mass  is  often  of  the  same  structure  as  the  thyroid  and  may  be 
considered  an  accessory  thyroid.  Accessory  thyroids  may  form  at  any 
part  of  the  thyreo-glossal  duct;  when  they  are  present  in  the  tongue 
they  are  sometimes  known  as  lingual  thyroids. 

The  duct  may  remain  open  throughout  its  whole  extent  as  a  passage 
lined  by  ciliated  epithelium.  The  lower  portions  may  be  provided 
with  diverticula.  In  other  instances  the  duct  becomes  converted  into 
a  j5.brous  cord.  Partial  obliteration  of  the  duct  often  gives  rise  to  reten- 
tion cysts  which,  according  to  their  sites,  may  cause  a  tumor  in  the 
floor  of  the  mouth  (some  forms  of  ranula),  in  the  tongue,"  or  in  the  me- 
dian line  of  the  neck.  Such  cysts  contain  mucoid  material  and  may 
vary  in  size  from  that  of  a  small  nut  to  a  small  orange. 

Fistulae  arising  from  the  thyreo-glossal  duct  never  possess  an  aper- 
ture through  the  skin  unless  they  have  perforated  the  skin  secondarily 
through  their  growth  or  because  of  inflammatory  changes.  Once  an 
external  fistula  forms  it  never  heals  unless  all  the  patent  canal  with  which 
it  communicates  is  excised.  Sometimes  (Fig.  72)  a  fibrous  cord  and 
fistula  lead  from  a  median  cyst  to  the  skin  lower  down  in  the  neck. 

Dermoid  cysts  and  fistula;  of  the  middle  line  of  the  neck  and  of  the 
tongue  are  commoner  than  the  mucous  variety  but  have  an  entirely 


Il6  REGIONAL   SURGERY 

different  origin,  being  due  to  imperfections  in  the  fusion  of  the  branchial 
arches  of  one  side  with  those  of  the  opposite  side.  Such  cysts  and  fis- 
tulas are  practically  identical,  except  in  situation,  with  the  lateral 
branchial  lesions. 

Treatment. — The  only  treatment  for  median  cysts  and  fistulae  of  the 
neck,  floor  of  the  mouth  or  tongue,  of  whatever  origin,  is  complete  exci- 


FiG.  72.- — Median  cyst  and  fistula  of  neck. 

sion.  Butlin  (Burghard,  Op.  Surg.,  II,  213)  has  seen  hypothyroidism 
result  from  the  removal  of  a  solid  thyreo-glossal  duct  tumor  from  the 
tongue.  It  must  be  remembered  that  an  apparently  accessory  thyroid 
may  be  the  real  functioning  gland. 


SECTION  VII 

INJURIES  AND  DISEASES  OF  THE  FACE  AXD  JAW 
(NOT  INCLUDING  CONGENIT.\L  DEFECTS) 

By 

J.  E.  SUMMERS,  M.  D.,  F.  A.  C.  S. 
Omaha,  >Jebraska 

Fractures  of  the  Lower  Jaw. — Fractures  of  the  lower  jaw  are  of  more 
frequent  occurrence  than  of  the  other  bones  of  the  face,  on  account  of  its 
position,  its  shape  and  its  size.  The  motiHty  of  the  head  and  the  natural 
impulse  of  the  individual  to  protect  the  face  from  anticipated  blows  and 
falls,  however,  prevent  many  fractures.     Fractures  are  more  common 


E  A 

Fig.  73. — Fractures  of  the  lower  jaw.  .4,  Fracture  of  the  alveolar  border;  B,  fracture 
of  the  condyle;  C,  fracture  of  the  coronoid  process;  D,  fracture  of  the  ramus;  E,  unilateral 
fracture:  EE',  double  fracture.     The  median  fracture  is  not  shown.     {Le  Dcnlu  el  Dclbet.) 

among  men  than  women  because  of  greater  exposure  in  their  daily 
occupations  (Fig.  73).  A  sudden  blow,  kick,  fall,  automobile  or 
run-over  accident,  may  break  the  lower  jaw,  and  it  depends  on  the 
location  and  direction  of  the  striking  force  as  to  what  part,  or  parts, 
of  the  bone  may  be  broken;  an  indirect  force,  e.g.,  a  blow  on  the  top 
of  the  head  when  the  chin  is  resting  on  a  hard  surface,  may  fracture 

117 


ii8 


REGIONAL   SURGERY 


the  jaw.  Fractures  of  the  alveolar  border  are  very  common,  often 
being  caused  by  dentists  in  extracting  teeth.  The  most  frequent 
fractures  occur  through  the  body  of  the  jaw  (40  out  of  43  cases, 
Hamilton);  usually  the  maxilla  is  fractured  toward  its  anterior 
extremity  where  the  bone  is  weakened  by  the  extreme  depth  of  the 
alveolus  of  the  canine  tooth.  The  line  of  fracture  usually  passes  ob- 
liquely downward  and  outward.  Displacement  of  the  fragments  (Fig. 
74),  depends  upon  two  factors,  the  direction  and  amount  of  the  contusing 
force,  and  the  traction  of  the  muscles  attached  to  the  different  frag- 
ments. When  only  one  side  is  fractured  the  rear  portion  is  drawn 
upward,  outward,  and  forward  by  the  masseter  and  temporal  muscles, 
while  the  anterior  fragment  is  drawn  in  the  opposite  direction  by  the 
hyoid  muscles;  the  smaller  fragment  then  overlaps  the  larger.     Frac- 


FiG.  74. — Lateral  fracture  of  the  body  of  the  lower  jaw.  A,  Traction  due  to  the  taas- 
seter,  the  internal  pterygoid  and  the  temporal  muscles;  B,  traction  due  to  the  genio-hyoid 
muscles.     (Le  Dentu  et  Delbet.) 

tures  of  the  median  portion  of  the  jaw  are  rare,  but  when  they  do  occur 
the  line  of  fracture  is  in  general  vertical,  and  there  is  very  slight  dis- 
placement. Multiple  and  comminuted  fractures  are  common,  and 
usually  the  fracture  is  compound  because  of  the  tearing  of  the  mucous 
membrane  of  the  mouth,  or  because  of  an  external  wound  of  the  soft 
parts  covering  the  jaw.  If  both  sides  are  broken  the  line  of  fracture  is 
most  often  at  the  canine  alveolus  on  one  side  and  just  anterior  to 
the  insertion  of  the  masseter  muscle  on  the  other  side;  the  diplace- 
ment  is  the  same  as  in  unilateral  fracture,  except  that  it  is  more  marked. 
Crepitation  is  very  noticeable,  and  this  in  itself  is  enough  to  show 
positively  the  existence  of  a  fracture.  The  patient  cannot  talk;  it  is 
impossible  for  him  to  chew,  and  deglutition  is  very  painful. 


INJURIES    AND   DISEASES   OF    THE    FACE    AND   JAW  II 9 

The  coronoid  process  is  very  rarely  fractured,  and  then  only  when 
associated  with  other  fractures.  If  the  ascending  ramus  is  fractured 
the  masseter  and  internal  pterygoid  muscles  prevent  displacement  of 
the  fragments.  A  fall  on  the  chin,  or  a  blow  on  the  side  of  the  jaw, 
may  fracture  the  condyle;  when  the  fracture  is  unilateral  the  condyle 
is  displaced  forward  by  the  external  pterygoid,  and  the  chin  is  deviated 
toward  the  affected  side.  If  both  condyles  are  broken,  the  lower  jaw  is 
displaced  backward  and  the  teeth  lose  their  natural  relations.  All 
fractures  of  the  lower  jaw,  behind  the  anterior  insertion  of  the  masseter 
muscle,  are  most  accurately  diagnosed  by  the  X-ray. 

Treatment. — As  most  fractures  are  compound  they  have  every  oppor- 
tunity to  become  infected  because  of  the  many  different  kinds  of  bac- 
teria always  present  in  the  mouth;  the  infection  is  seldom  of  a  severe 
type.  Treatment  consists,  as  in  other  fractures,  first,  in  reducing  the 
fracture,  and  second,  in  the  fixing  of  the  bone  so  that  the  fragments  will 
unite  in  such  a  way  that  there  shall  be  proper  alignment  of  the  teeth.  In 
fractures  of  the  body,  if  there  is  not  much  displacement,  the  surgeon 
moulds  the  parts  into  proper  shape,  sees  that  there  is  a  proper  alignment 
of  the  teeth,  closes  the  mouth  and  holds  the  lower  jaw  firmly  against  the 
upper  jaw.  If  there  is  much  displacement  more  manipulation  is 
required  in  the  reduction:  the  ends  have  to  be  drawn  in  opposite  direc- 
tions to  overcome  the  overlapping;  the  disturbed  teeth  should  be 
replaced  in  proper  alignment.  If  a  tooth  is  found  free  in  the  mouth,  or 
between  fragments,  an  attempt  should  be  made  to  save  it  by  replacing 
it  in  its  socket,  binding  it  if  necessary  to  its  neighbors  by  a  silver  wire. 
A  careful  examination  for  the  presence  of  a  tooth  between  the  fragments 
should  never  be  neglected.  The  writer  has  seen  one  case  where  such  a 
complication  prevented  union  for  three  months  before  discovery  and 
removal  of  the  tooth  resulted  in  prompt  repair.  Reduction  having  been 
affected,  it  is  maintained  in  the  majority  of  cases  by  the  use  of  a  four- 
tailed  jaw  bandage,  or  the  Barton  bandage,  applied  directly  over  a 
mould  made  of  pasteboard,  felt,  or  leather,  the  vertical  arms  of  which 
should  pass  well  up  upon  the  side  of  the  jaw.  The  bandage  binds  the 
lower  jaw  firmly  against  the  upper  jaw. 

Repair. — These  fractures  usually  unite  in  four  or  five  weeks  with- 
out deformity  sufficient  to  cause  functional  impediment.  Non-union 
seldom  or  never  occurs.  If  all  the  teeth  are  present  there  may  not  be 
sufiicient  space  between  the  upper  and  lower  teeth  for  the  administra- 
tion of  liquid  nourishment  and  the  proper  cleansing  of  the  mouth,  without 
loosening  the  bandage  for  the  introduction  of  food:  this,  in  a  degree, 


I20  REGIONAL    SURGERY 

disturbs  the  fragments,  causes  pain  and  delays  union.     Pieces  of  non- 
vulcanized  gutta  percha  (base-plate  gutta  percha  which  is  insoluble, 
softens  at  200°F.,  dry  heat,  hardens  at  go°F.,  and  is  quite  rigid,  is  the 
best  material,  and  does  not  require  vulcanization),  may  be  softened  in 
hot  water,  formed  into  wedges,  and  placed  on  either  side  over  the  crowns 
of  the  teeth,  the  one  on  the  fractured  side  covering  as  nearly  as  possible, 
near  its  middle,  the  line  of  fracture.     The  jaw  is  closed  and  pressed 
firmly  against  the  upper  jaw  until  the  teeth  on  each  side  of  the  fracture 
are  in  perfect  alignment.     When  the  gutta  percha  has  hardened  it  is 
removed  and  trimmed  so  as  not  to  irritate  the  sides  of  the  cheek  or  the 
tongue.     Then  a  sufficient  number  of  the  opposite  teeth  of  the  two 
jaws  may  be  wired,  one  to  another,  to  hold  the  interdental  splint  firmly 
in  position,  or  reliance  for  this  purpose  may  be  placed  upon  the  appli- 
cation of  a  four-tailed  bandage.     Even  when  the  wiring  is  resorted  to,  a 
four-tailed  bandage  should  be  employed  to  give  further  support.     This 
interdental  splint  allows  a  sufficient  space  between  the  teeth  to  admit  of 
the  giving  of  a  bounteous  quantity  of  soft  food,  and  the  frequent  irri- 
gation of  the  mouth  which  is  most  essential  to  the  comfort  of  the  patient 
and  for  the  removal  of  the  causes  of  bad  breath  due  to  putrefaction  within 
the  mouth.     The  method  of  introducing  food  through  a  tube  passed 
through  the  nose,  or  behind  the  last  molar  tooth,  is  exceedingly  dis- 
agreeable  and   painful   to  the  patient  and  should  not  be  practised. 
These  methods,  however,  and  the  administration  of  food  by  the  rectum, 
may  be  used  as  temporizing  measures  when  the  injury  is  complicated 
by  serious  shock  due  to  more  extensive  injuries  than  the  fracture  of  the 
lower  jaw  alone.     Many  forms  of  ingenious  interdental  splints  have  been 
introduced  by  dentists,  and  in  important  cases  it  may  be  wise  to  seek  a 
dentist's  aid.     A  number  of  intrabuccal  forms  of  apparatus  have  been 
introduced,  but  all  have  the  practical  defect  that  they  necessitate  the 
taking  of  an  impression  of  the  fractured  dental  arch,  which  is  a  difficult 
and  painful  manoeuver  besides  requiring  the  material  and  skill  of  a 
specialist  in  dental  surgery.     The  Kingsley  apparatus  is  probably  the 
most  useful  of  this  kind.     It  is  indicated  particularly  in  bilateral 
fracture  of  the  mandible  or  in  any  case  where  there  are  two  or  more 
fractures  of  the  mandible.     It  is  contraindicated  where  there  is  much 
oedema  and  infection  resulting  in  external  suppuration.     Great  care 
should  be  exercised  in  placing  the  bandages  under  the  chin  as  too  much 
pressure  is  apt  to  result  in  pressure  necrosis.     The  Kingsley  splint 
(Figs.  75  and  76)  is  contraindicated  in  any  single  fracture;  other  methods 
may  be  better  applied.     A  ready-made  form  of  apparatus  is  that  of 


INJURIES    AND    DISEASES    OF   THE   FACE    AND   JAW 


121 


Matas,  which  consists  of  three  different-sized  soft  block  tin  moulds, 
shaped  to  conform  to  the  usual  line  of  the  teeth  in  different  aged  and 
developed  individuals;  the  moulds  are  attached  to  aluminum  chin 
plates.  The  downward  pressure  of  the  block  tin  moulds,  and  the 
counter-pressure  of  the  aluminum  cup-shaped  chin  plate  (Fig.  77),  is 
made  by   a   thumb   screw.     In  use  the  apparatus  is  reinforced  by  a 


Fig.  75. — Kingsley  splint,  showing  under  surface  with  indentations.     {Le  Dentu  el  Ddbcl.) 

four-tailed  bandage.  Some  surgeons  resort  to  a  direct  suture  of  the 
bone  with  heavy  wire;  this  seems  unnecessary  unless  there  may  be 
unusual  complications,  with  more  or  less  contusion  and  division  of  the 
soft  parts;  the  wire  suture  is  passed  through  drill-holes  made  in  the 
bone  below  the  level  of  the  roots  of  the  teeth.  It  can  usually  be  re- 
moved in  three  weeks.  When  the  alveolar  bor- 
der is  fractured  it  should  be  carefully  reduced, 
broken  or  detached  teeth  should  be  placed  in 
their  natural  positions,  resorting  to  the  use  of 
silver  wire  to  secure  them  if  necessary,  and  the 
parts  immobilized  as  in  other  fractures  of  the 
body  of  the  jaw.  No  fragments  of  bone  should 
be  removed,  as  all  fragments  quickly  unite  be- 
cause of  the  vascularity  of  the  parts.  In  frac- 
tures of  the  neck  of  the  condyle  the  displacement 
of  the  condyle  by  the  external  pterygoid  may  be 
difficult  to  overcome.  It  should  be  reduced  as 
far  as  possible,  and  the  jaw  immobilized.  If 
there  is  marked  deviation  of  the  chin  toward  the 
fractured  side,  Sebilean  overcomes  this  by  fasten- 
ing a  metallic  ring  or  wire  around  the  superior  canine  tooth,  another 
on  the  inferior  large  molars,  and  uniting  these  together  by  a  heavy 
rubber  band.  This  produces  continued  extension  on  the  line  of  frac- 
ture. Fountain  obtains  the  same  results  by  wiring  the  teeth  together 
after  the  jaw  has  been  brought  well  forward.  Landry  recommends, 
and   has  employed  at  the  suggestion  of  Matas,  an  Esmarch  elastic 


Fig 


76. — Kingsley  splint 
applied. 


122  REGIONAL   SURGERY 

bandage;  this  is  used  in  multiple  fractures  of  the  jaw,  or  marked  com- 
pound cases  with  separation  of  the  alveolar  process,  or  cases  with 
great  swelUng  and  hemorrhage  forbidding  an  intrabuccal  appHance 
owing  to  pain  and  inability  to  keep  the  mouth  clean.  It  is  applied 
over  sufi&ciently  copious  aseptic  dressings,  taking  five  or  six  turns 
around  the  head  and  chin,  bringing  the  crowns  of  the  teeth  of  the  lower 
jaw  into  contact  with  those  of  the  upper,  and  at  the  same  time  favoring 
and  promoting  the  reduction  and  absorption  of  subcutaneous  hem- 
orrhage and  oedema.  It  is  recommended  particularly  in  young  chil- 
dren, as  the  milk  teeth  are  not  strong  enough  to  support  any  sort  of 
prosthesis. 


Fig.  77. — Matas  splint.     (Matas.) 

Fractures  of  the  Nose.— As  the  result  of  direct  violence  one  or  both 
nasal  bones  may  be  broken  and  the  cartilages  may  be  dislocated. 
Usually  a  tear  of  the  mucous  membrane  renders  the  fracture  compound, 
but  anything  further  than  a  mild  sepsis  seldom  follows.  Either  the 
nose  is  displaced  to  one  side  or  the  nasal  bones  are  crushed  in,  forming 
a  flattening  of  the  bridge,  the  so-called  "saddle  nose."  In  the  lateral 
displacement  the  cartilage  of  the  septum  may  be  carried  to  the  same 
side,  and  when  the  bridge  is  crushed  in,  the  cartilaginous  septum  bends 
upon  itself  or  tears  at  its  junction  with  the  ethmoid  or  vomer.  The 
perpendicular  plate  of  the  ethmoid  may  likewise  fracture,  and  the 
injury  may  even  carry  a  fissure  upward  through  the  bone  to  the  base  of 
the  brain.  The  nasal  ducts  are  sometimes  injured  in  such  a  manner 
as  to  obstruct  the  downward  flow  of  tears;  possibly  a  lachrymal  abscess 


INJURIES    AND    DISEASES    OF    THE    FACE    AND   JAW  1 23 

may  form;  there  is  always  more  or  less  bleeding  from  the  nose,  but  it  is 
seldom  sufficiently  alarming  to  cause  apprehension  and  require  plugging 
of  the  cavity. 

Treatment. — In  lateral  displacements  the  sides  of  the  nose  may  be 
moulded  into  shape  by  the  lingers,  aided  or  not  by  a  suitable  blunt 
instrument  passed  into  the  nose.  In  crushed-in  or  "saddle  nose"  the 
same  procedure  may  be  followed;  in  some  cases,  however,  it  is  necessary 
to  grasp  the  septum  between  the  blades  of  a  strong  forceps  and,  with  a 
slight  rocking  motion,  elevate  the  bones,  while  with  the  thumb  and 
fingers  of  the  other  hand,  the  nose  is  moulded  into  shape.  While  a 
general  anaesthesia  is  desirable,  in  the  less  severe  injuries  a  local  anaes- 
thetic will  suffice.  Blowing  of  the  nose  after  these  injuries  may  cause 
emphysema  of  the  face,  the  air  entering  through  the  torn  mucous 
membrane;  it  should  not  cause  serious  apprehension.  To  retain  the 
reduced  fracture  in  position,  often  all  that  is  necessary  is  to  put  a 
small  gauze  pad  on  one  or  each  side,  resting  partly  upon  the  superior 
maxilla  and  partly  upon  the  nasal  bones,  and  fasten  these  pads  in 
position  by  a  strip  of  adhesive  plaster  crossing  both  cheeks.  In  the 
crushed-in  cases,  it  may  be  necessary  to  gain  support  from  within,  using 
iodoform  gauze  packing,  so  as  to  push  the  septum  into  position  and 
support  the  nasal  bones.  A  long,  straight  needle  may  be  passed  from 
side  to  side  through  the  base  of  the  nose,  to  assist  in  the  prevention  of 
the  caving-in  of  the  replaced  "saddle  nose";  the  ends  of  the  needle 
should  be  protected  with  cork.  There  is  always  an  inflammatory 
swelling  which  interferes  with  breathing  through  the  nose,  but  this 
subsides  in  a  few  days  as  repair  progresses.  Union  is  fairly  firm  in  lo 
or  15  days.  Suppuration  and  necrosis  occasionally  follow,  delaying 
repair,  particularly  if  there  has  been  much  comminution  of  the  frag- 
ments. Because  of  the  early  swelling  it  is  not  always  easy  to  make 
perfect  reduction  of  the  displaced  nose,  and  quite  commonly  evidence 
of  the  injury  may  be  seen  in  after  years;  particularly  is  this  so  after 
crushed-in  injuries. 

Fractures  of  the  Upper  Jaw. — Fractures  of  the  upper  jaw  are  pro- 
duced under  two  different  conditions:  first  and  most  commonly,  by  a 
direct  shock,  as  a  blow  in  the  face  or  a  gun-shot  wound;  second,  and  of 
less  clinical  interest,  by  a  force  striking  some  other  point  than  that  where 
the  line  of  fracture  starts  causing  indirect  or  radiated  fractures.  The 
upper  jaw  is  most  likely  to  be  fractured  along  any  one  of  several  different 
lines  (Fig.  78)  :  first,  the  alveolar  border,  rarely  its  entire  length;  second, 
a  line  of  fracture  may  pass  horizontally  around  the  jaw  just  at  the  nasal 


124  REGIONAL    SURGERY 

orifice.  A  third  line  may  start  near  the  middle  of  the  nasal  bones,  run 
backward  through  the  orbit,  strike  the  pterygoid  apophysis  and  break 
the  zygomatic  apophysis.  Another  (fourth)  line  of  fracture  is  a 
branch  of  the  last  line  separating  from  it  in  the  orbit,  and  extending 
downward  through  the  suborbital  opening,  then  backward  and  upward 
again,  to  the  main  line.  As  in  the  lower  jaw,  small  portions  of  the 
alveolus  may  be  broken  in  the  extraction  of  teeth.  Most  of  the  fractures 
of  the  superior  maxillas  are  benign,  even  though,  through  the  tearing 
of  the  mucous  membrane,  they  may  open  into  the  mouth — an  ex- 
tremely septic  place. 


Fig.   78. — Lines  of  weakness  in  the  bones  of  the  upper  jaw;  RV,  First  line — alveolar  border; 
ABCD,  second  line;  EHOCD,  third  line;  and  EHBCD,  fourth  line.     (Le  Dentu  el  Delbet.) 

Treatment. — Any  fracture  should  be  reduced  as  soon  as  possible,  and 
kept  in  an  aseptic  condition.  Fractures  of  the  alveolar  border,  after 
being  reduced,  may  be  held  in  position  by  means  of  a  gutta-percha 
mould  such  as  is  used  in  fractures  of  the  lower  jaw;  the  upper  and  lower 
jaws  should  be  pressed  firmly  together  and  held  in  this  position,  thus 
preserving  the  proper  alignment  of  the  teeth.  The  four-tailed  bandage 
may  also  be  used — applied  as  in  fractures  of  the  lower  jaw. 

The  zygomatic  process  of  the  malar  bone  is  sometimes  broken,  allow- 
ing the  malar  bone  to  rock  forward  and  break  into  the  antrum;  this 
fracture  is  readily  recognized  by  the  flattening  of  the  side  of  the  face; 
the  fracture  may  be  reduced  by  manipulation,  or  the  bene  may  be 


mjURIES    AND    DISEASES   OF    THE    FACE    AND    JAW  1 25 

elevated  into  position  by  inserting  a  suitable  instrument  through  an 
opening  made  in  the  mucous  membrane  in  front  of  the  anterior  border 
of  the  masseter  muscle.  The  zygomatic  arch  may  be  crushed  in  by  a 
blow  in  such  a  way  as  to  interfere  with  the  function  of  the  lower  jaw. 
The  fragments  should  be  elevated  by  manipulation,  or  after  incision. 

The  Temporo-maxillary  Joint. — The  intra-articular  cartilage  may 
become  loose,  and  interfere  with  the  function  of  the  jaw,  when  there  is 
quite  constantly  to  be  heard  a  crackling  sound  upon  movement  of  the 
jaw,  and  if  these  movements  are  exaggerated  a  temporary  locking  may 
occur.  The  condition  is  seldom  more  than  an  annoyance  but  should 
the  interference  of  function  justify,  it  may  be  relieved  by  removing  the 
cartilage  or  the  cartilage  may  be  sutured  into  position  (Annandale). 

Arthritis  of  the  Temporo-maxillary  Joint. — Arthritis  may  be 
either  acute  or  chronic.  The  acute  form  is  sometimes  due  to  trauma- 
tism but  more  commonly  occurs  as  a  sequel  or  complication  of  con- 
stitutional infections,  particularly  the  exanthemata.  It  is,  therefore, 
more  common  in  children  than  in  adults.  The  symptoms  are  pain, 
tenderness,  redness  and  swelling.  Movements  increase  the  pain. 
Should  suppuration  be  added,  constitutional  symptoms  may  be 
marked.  The  abscess  may  point  toward  the  surface  over  the  joint,  or, 
as  in  a  recent  case  of  the  writer's,  it  may  pass  through  the  tympanic  plate 
and  appear  as  an  otorrhea.  The  suppurative  form  may  have  its  origin 
in  middle-ear  disease,  osteomyelitis  of  the  lower  jaw,  or  parotitis,  the 
infection  spreading  by  direct  contiguity.  If  the  arthritis  does  not 
become  suppurative  the  inflammatory  products  are  absorbed,  restora- 
tion of  function  takes  place  or  fibrous  ankylosis  ensues.  Following 
suppuration  there  may  be  complete  disorganization  of  the  joint,  re- 
sulting in  bony  ankylosis. 

Treatment. — The  indications  for  treatment  of  the  non-suppurative 
inflammations  are  the  application  of  an  ice-bag  over  the  joint;  talking 
should  be  interdicted  and  the  jaw  should  be  supported  by  a  suitable 
bandage  passed  under  the  chin  and  around  the  head.  Early  evacuation 
and  drainage  of  the  pus  is  indicated  in  suppurative  arthritis;  in  order  to 
obtain  proper  drainage  it  may  be  necessary  to  resect  the  joint.  An 
extraarticular  origin  of  the  infection  must  receive  appropriate  treat- 
ment.    Rationally  selected  mixed  stock  vaccines  may  be  useful. 

Fixation  of  the  Jaw. — Spasmodic  or  temporary  closure  of  the  jaw 
is  due  to  a  contraction  of  the  muscles  of  mastication.  When  due  to  an 
irritation  of  the  mandibular  division  of  the  fifth  cranial  nerve  it  is 
called  trismus,  and  this  may  be  caused  by  an  impaction  of  a  third  molar 


126 


REGIONAL    SURGERY 


tooth.  An  X-ray  examination  will  disclose  this  condition  and  the 
removal  of  the  tooth  will  immediately  relieve  the  symptoms  (Fig.  79). 
Inflammations  of  the  parotid  gland  and  of  the  tonsil,  carious  teeth  and 
local  osteomyelitis  of  the  jaw  may  cause  temporary  trismus,  which 
disappears  with  the  removal  of  the  irritation.  Trismus  is  occasionally 
simulated    by    hysterical    subjects    and    is    then    best    overcome   by 


Fig.  79. — Impacted    third    molar 
tooth. 


Organic  Fixation  of  the  Jaw. — Murphy  divides  these  fixations  into 
four  classes:  i.  Intra-articular  conditions;  this  may  be  a  fibrous 
ankylosis.  2.  Bony  ankylosis.  3.  Peri-articular  conditions.  4.  Extra- 
articular muscular  or  cicatricial  fixation  on  the  side  of  the  face  or  cheek, 

or  a  binding  together  of  the  alveolar  proc- 
esses from  cicatrization  following  slough- 
ing within  the  mouth. 

The  diagnosis  as  to  the  variety  of 
fixation  will  depend  upon  the  history  of 
the  case  and  the  local  examination.  The 
recognition  of  which  side  is  ankylosed  is 
sometimes  a  delicate  decision  and  mis- 
takes have  been  made  by  experienced 
surgeons.  The  asymmetry  of  the  face  is 
not  a  constant  sign  of  unilateral  ankylo- 
sis, but  usually  the  face  is  flattened  on 
the  side  ankylosed.  Under  anaesthesia, 
however,  it  is  always  possible  to  obtain  a  slight  opening  of  the  jaw 
for  from  5  to  10  mm.  on  the  healthy  side. 

Treatment  of  Organic  Fixation  (Ankylosis). — All  forms  of  organic 
fixation  of  the  jaw  are  subject  to  a  common  danger  during  general 
anaesthesia,  and  this  danger  is  asphyxia.  It  may  arise  from  one  of 
two  causes :  first,  the  entrance  of  vomited  matter  into  the  air  passages, 
second,  the  falling  back  of  the  tongue  into  the  pharynx,  the  so-called 
"swallowing  of  the  tongue";  this  must  not  be  forgotten.  It  has  been 
proposed  by  some  to  resort  to  a  preliminary  preventive  tracheotomy, 
and  the  surgeon  must,  at  least,  always  be  ready  to  do  a  tracheotomy 
should  the  occasion  demand. 

If  the  fixation  is  fibrous,  it  is  possible  that  it  may  be  overcome  by 
progressive  dilatation  of  the  mouth  by  different  varieties  of  dilators. 
This  can  only  be  hoped  for  if  treatment  is  instituted  at  a  reasonably 
early  period  after  the  development  of  the  fixation  and  there  is  still 
some  motility.     Forced  dilatation  under  general  anaesthesia  has  proven 


INJURIES   AND   DISEASES    OF   THE   FACE    AND    JAW  1 27 

a  failure  as  experience  has  shown  that  any  improvement  is  soon  lost. 
Fibrous  ankylosis  which  cannot  be  overcome  by  gradual  dilatation,  or 
bony  ankylosis,  are  best  remedied  by  resection  of  the  temporo-maxillary 
joint,  or  by  division  of  the  neck  of  the  condyle.  There  are  two  draw- 
backs to  this  procedure:  one,  the  danger  of  injuring  the  facial  nerve, 
and  the  other,  the  tendency  to  recurrence  of  the  ankylosis.  Injury 
to  the  facial  nerve  can  be  avoided  by  a  proper  incision  both  as  to  posi- 
tion and  direction,  and  recurrence  of  the  ankylosis  prevented  by  insert- 
ing and  fixing  in  the  glenoid  fossa,  a  flap  of  fat  and  fascia  from  the 
temporal  muscle,  between  the  two  bones  from  which  the  temporal 
maxillary  joint  was  formed  (Nicoladini).  The  incision  generally 
employed  is  a  slightly  curved  one  2  inches  in  length,  commencing  on 
the  zygoma  about  3^^  inch  in  front  of,  and  on  a  level  with  the 
auditory  canal.  The  incision  is  carried  upward  over  the  zygoma  into 
the  hair,  dividing  the  skin  and  superficial  fascia.  The  superficial 
temporal  artery  and  veins  usually  lie  behind  this  incision  but  if  en- 
countered and  in  the  way,  they  should  be  ligatured.  The  wound  is 
retracted  as  the  fascia  is  elevated  from  the  zygoma  with  a  periostotome. 
This  manceuver  separates  the  capsule  from  the  condyle  below,  and 
exposes  the  joint.  It  must  be  borne  in  mind  that  the  auriculo-temporal 
nerve  runs  up  behind  the  condyle,  while  the  internal  maxillary  artery 
crosses  below.  The  condyle  is  elevated  into  the  incision  and  divided 
with  bone  forceps.  If  the  meniscus  is  diseased,  it  is  excised.  In  some 
instances  it  may  be  advisable  to  divide  the  neck  of  the  condyle  for  the 
interposition  of  the  fascial  flap,  since  rough  elevating  or  gouging  of 
the  ankylosed  head  might  result  in  injury  to  the  base  of  the  brain,  as 
the  roof  of  the  glenoid  fossa  is  very  thin.  If  more  room  is  required, 
the  zygoma  should  be  resected.  In  order  to  prevent  recurrence  of 
the  ankylosis,  Helferich,  in  1893,  practised  the  first  resection  with  the 
interposition  of  a  muscular  flap.  He  turned  down  into  the  glenoid 
fossa  a  flap  from  the  posterior  border  of  the  temporal  muscle,  having 
made  a  preliminary  resection  of  the  zygomatic  arch,  and  sutured  its 
free  extremity  to  the  aponeurosis  of  the  parotid  gland  (Fig.  80). 
Huguier  accomplished  the  same  object  by  interposing  a  flap  of  muscle 
taken  from  the  posterior  part  of  the  masseter  muscle,  the  base  of  the 
flap  being  upward.  The  extremity  was  sutured  as  in  Helferich's 
operation.  The  zygoma,  of  course,  was  not  resected.  These  were 
successful  methods,  but  to-day  surgeons  of  most  experience  in  this 
operation  prefer  to  interpose  in  the  joint  a  flap  of  the  temporal  fascia. 
Difficulty  in  opening  the  jaw,  when  due,  not  to  intra-articular  disease 


128 


REGIONAL   SURGERY 


but  to  shortening  and  adhesion  of  the  soft  structures,  can  be  treated 
in  two  ways:  first,  the  shortened  masseter  and  internal  pterygoid 
muscles  can  be  loosened  from  their  attachment  to  the  inferior  maxilla. 
To  do  this  an  incision  is  made  under  the  jaw  and  toward  its  buccal 
border,  to  avoid  a  scar.  With  an  elevator  the  masseter  and  the  lower 
part  of  the  internal  pterygoid  are  freely  loosened,  care  being  taken  not 
to  extend  the  loosening  of  the  latter  so  high  as  to  injure  the  inferior 
maxillary  nerve  and  vessels.  Second,  the  difficulty  can  be  treated  by 
making  a  false  joint  in  front  of  the  adhesions  and  resecting  the  jaw. 


FiG.'(8o. — Resection  of  the  maxillary  condyle,  interposition  of  a  muscular- flap  from  the 
"itemporal  muscle.     T,  Temporal  muscle;  M,  masseter  muscle.     {Le  Dentu  et  Delbet.) 


The  location  of  the  resection  must  be  varied  to  suit  different  cases. 
The  piece  of  bone  resected  should  be  wedge-shaped  with  its  apex  at  the 
alveolar  border,  and  should  be  made  in  such  a  part  of  the  jaw  as  to 
re-establish  the  center  of  motion  as  nearly  comparable  as  possible  with 
that  which  is  normal.  The  masseter  and  internal  pterygoid  muscle? 
can  be  used  in  interposition  between  the  ends  of  the  divided  bone. 
The  operation  of  Rizzoli-Esmarch,  i.e.,  the  making  of  a  false  joint  in 
front  of  the  adhesions,  and  resecting  the  jaw,  is  not  particularly  to  be 
commended,  as  many  failures  follow.     It  is  better  in   the  majority 


INJURIES    AND    DISEASES    OF    THE    FACE    AND    JAW  1 29 

of  cases,  to  make  a  total  extirpation  of  all  cicatricial  tissue  and  to  fill 
in  the  defect  by  an  immediate  autoplastic  operation.  These  auto- 
plastics may  be  carried  out  by  mobilizing  flaps  taken  from  the  nighbor- 
ing  regions,  from  the  arm  directly,  or  "jump-flaps"  may  be  taken 
from  the  abdomen  to  the  arm,  and  from  the  arm  to  the  defect. 

Dislocation  of  the  Jaw.^ — Dislocation  of  the  jaw  may  be  unilateral 
but  it  is  more  commonly  bilateral;  the  displacement  is  forward.  The 
accident  seldom  occurs  among  children  or  the  aged  and  is  most  common 
among  females.  When  the  mouth  is  unduly  opened  in  yawning,  laugh- 
ing, attempting  to  take  too  large  bites,  the  condyle  slips  forward  on 
top  of  the  articular  eminence  and  should  the  external  pterygoid  muscle 
contract  sufficiently  the  condyle,  with  its  meniscus,  is  drawn  over  the 
eminence  into  the  hollow  under  the  zygoma,  and  is  held  in  this  position 
by  the  contraction  of  the  temporal  and  masseter  muscles.  Down- 
ward blows  upon  the  chin  or  body  of  the  jaw,  and  unskilled  use  of 
the  mouth  gag,  have  frequently  caused  the  displacement.  In  some 
individuals  a  tendency  to  this  accident  is  explained  by  relaxation  of  the 
capsule,  as  in  habitual  dislocation  of  the  shoulder  joint. 

Symptoms.- — The  jaw  is  rigid,  the  chin  is  projected  forward  so  that 
the  lower  teeth  project  beyond  those  of  the  upper  jaw,  and  the  condyle  can 
be  felt  in  its  abnormal  position;  the  coronoid  process  may  be  felt  below 
the  malar  bone.  The  temporal  muscle  is  tense.  In  unilateral  disloca- 
tion the  chin  is  directed  toward  the  uninjured  side.  The  mouth  cannot 
be  closed,  saliva  dribbles,  and  speech  is  guttural  and  indistinct. 

Treatment. — Reduction  is  usually  easily  effected.  The  patient  is 
placed  upon  a  low  stool  or  chair  with  an  assistant  standing  behind  and 
firmly  supporting  the  head.  The  operator  stands  in  front  of  the  patient 
and,  having  protected  his  thumbs  with  a  number  of  thicknesses  of 
gauze,  places  them  as  far  back  as  possible  upon  the  molar  teeth,  while 
with  his  fingers  he  grasps  the  body  of  the  jaw.  With  a  downward  and 
backward  pressure,  to  overcome  the  contraction  of  the  temporal  and 
masseter  muscles,  and  a  slightly  rotary  motion,  the  condyles  are  low- 
ered out  of  their  false  position  into  the  glenoid  fossa.  In  order  to  carry 
out  this  manoeuver,  the  chin  must  be  lifted  upward,  the  reduction  being 
the  reverse  of  the  mechanism  of  the  dislocation.  In  difficult  cases  a 
cork  or  piece  of  soft  wood  may  be  placed  between  the  molars  on  each 
side,  to  act  as  a  fulcrum,  and  the  jaw  levered  into  place.  The  after- 
treatment  consists  in  limiting  the  motion  of  the  jaw  for  a  few  days  by 
means  of  a  four-tailed  bandage,  and  the  patient  should  be  warned 
against  opening  widely  the  mouth. 
9 


I30 


REGIONAL    SURGERY 


In  old  cases,  when  manipulative  measures  of  reduction  fail,  if  inter- 
ference with  eating,  the  dribbling  of  saliva,  and  general  discomfort  of 
the  deformity  justifies,  operative  measures  are  indicated.  The  con- 
tracted masseter  and  internal  pterygoid  muscles  may  be  loosened  from 
their  attachments  to  the  inferior  maxilla  through  an  incision  under  the 
jaw,  and  then  by  manipulation  reduction  may  be  possible.  Failing  in 
this  the  condyles  should  be  resected. 

Incised  and  Contused  Wounds  of  the  Face. — Incised  wounds  are 
usually  caused  by  sharp  cutting  instruments,  but  at  certain  locations 


Fig.  8i. — Incised  wounds  of  the  face,  gaping  widely  because  of  the    muscle    traction 

(Morestin.) 


an  ordinary  blow  from  any  cause,  particularly  a  hard,  round  instrument 
like  a  policeman's  club,  may  produce  a  wound  similar  to  an  incised 
wound,  except  that  its  edges  are  apt  to  be  irregular  and  somewhat 
contused:  the  tissues  of  the  soft  parts,  catching  between  the  striking 
instrument  and  the  bone  beneath,  are  spUt.  This  is  likely  to  occur 
on  the  forehead,  the  cheek,  and  the  chin;  the  lips  are  often  badly 
wounded  by  being  caugHt  between  or  driven  against  the  teeth.  All 
incised  wounds  of  the  face  bleed  freely,  and  in  the  cheek  especially 


INJURIES    AND    DISEASES    OF    THE    FACE    AND    JAW  131 

they  gape  widely  because  of  the  insertion  of   the    muscles   into   the 
skin  (Fig.  8i). 

Contused  wounds  are  by  far  the  more  common;  they  are  brought 
about  by  blows,  falls,  run-over  or  automobile  accidents,  explosions,  and 
injuries  from  fire-arms,  or  entanglement  in  machinery.  Very  often 
such  an  extent  of  laceration  accompanies  these  wounds  as  to  cause 
serious  shock. 

Punctured  wounds  are  the  most  dangerous;  they  may  easily  become 
infected  by  poisonous  germs  introduced  with  the  inflicting  instrument, 
and  from  the  nature  of  the  wound  it  cannot  bleed  freely  and  thus  help 
to  eliminate  the  germs. 

In  all  these  wounds,  the  first  object  should  be  the  control  of  hemor- 
rhage; second,  thorough  cleansing  of  the  wound  and  removal  of  all 
foreign  substances^ — small  pieces  of  stone  or  coal,  grains  of  fine  powder, 
small  shot,  etc.;  third,  careful  repair  of  injuries.  Powder  may  be  re- 
moved and  stains  prevented  by  (under  a  general  anaesthetic)  thoroughly 
scrubbing  the  afTected  skin  with  a  stiff  nail  brush,  using  preferably  some 
pumice  soap,  such  as  "Jumbo."  The  surface  should  be  scrubbed  until 
it  becomes  sufficiently  raw  so  that  the  grains  of  powder  are  removed. 
From  time  to  time  during  the  scrubbing  the  raw  area  ought  to  be 
cleansed  by  a  non-irritating  antiseptic  solution.  Deeply  imbedded 
grains  may  have  to  be  cut  out.  The  raw  surface  should  be  covered  by  a 
non-irritating  antiseptic  ointment  spread  upon  a  protective  mask.  In 
a  few  days  the  skin  begins  to  repair.  Usually,  unless  there  has  been  a 
complicating  deep  burn,  very  little  deformity  results.  If  there  has 
been  much  dirt  ground  into  a  wound  it  is  a  wise  precautionary  measure 
to  given  an  immunizing  dose  of  antitetanus  serum,  as  the  tetanus 
germs  find  ready  entrance  to  the  medulla  along  the  nerves  and  the 
blood  stream.  A  very  dangerous  though  rare  form  of  tetanus  follows 
infection  of  areas  supplied  by  the  cranial  nerves,  especially  in  the 
neighborhood  of  the  supraorbital  branches.  It  is  characterized  by 
paralysis  of  the  facial  nerve  with  trismus,  and  at  times  by  great  difiiculty 
in  swallowing.  A  maniacal  frenzy  is  sometimes  observed.  There  may 
be  more  or  less  general  tonic  muscular  spasms. 

When  the  tissues  are  badly  lacerated  and  more  particularly  when 
the  wounds  are  of  the  punctured  variety,  careful  antisepsis  is  of  the 
greatest  importance  in  order  to  bring  about  repair  and  the  prevention  of 
the  formation  of  scars,  the  result  of  healing  by  granulation.  All 
punctured  and  other  kinds  of  wounds  where  infection,  particularly 
with  the  germ  of  tetanus,  is  probably  present,  should  be  freely  opened, 


132  REGIONAL   SURGERY 

foreign  bodies  removed,  and  the  wound  cleansed  by  first  using  peroxide 
of  hydrogen,  because  of  the  anaerobic  character  of  the  tetanus  bacillus, 
then  thoroughly  antisepticized  with  pure  carbolic  acid;  this  should  be 
washed  away  with  95  per  cent,  alcohol.     Tincture  of  iodine,  or  a  satur- 
ated solution  of  permanganate  of  potassium  may  be  employed  instead 
of  the  carbolic  acid  and  alcohol.     All  such  wounds  should  be  treated  on 
the   open,   free-drainage  plan.     The  precautionary  administration  of 
antitetanus  serum  is  always  advisable.     If  the  mucous  membrane  of 
the  mouth  or  eyelid  is  torn  or  cut,  its  edges  should  be  joined  together 
separately  from  the  approximation  of  the  torn  edges  of  tissue,  skin,  etc. 
The  tendency  to  repair,  in  wounds  of  the  face,  is  very  remarkable,  due 
to  the  extreme  vascular  richness  of  the  skin  and  tissues;  if  non-absorb- 
able  sutures  have  been  introduced,  they  may  be  removed  in  three  to 
five  days.     Following  wounds  of  the  face,  repair  may  result  in  con- 
siderable deformity  and  blemish  by  the  adherence  of  the  cicatrix  to 
the  underlying  bone.     Binnie  says,  "Many  otherwise  beautiful  faces 
are  deformed  by  the  presence  of  depressed  scars  adherent  to  the  under- 
lying bone.     Sometimes  such  scars  may  be  neatly  excised  with  gratify- 
ing results,  but  sometimes  such  treatment  is  unsuitable  or  fails.     Sub- 
cutaneous division  of  the  adhesion  between  the  skin  and  the  bone  may 
do  good,  but  it  does  not  replace  the  tissues,  the  loss  of  which  was  the 
cause  of  the  depression.     If  through  an  incision  the  adhesions  are 
thoroughly  divided,  and  if  then  (after  hemostasis  is  attained  by  pres- 
sure) a  suitable  mass  of  fat  is  gently  insinuated  through  the  cut  to  fill 
up  the  depressed  area,  an  ideal  result  may  be  obtained.     It  is  best  to 
obtain  the  fat  for  transplantation  from  the  patient  himself  (autoplasty) , 
as  homoplasty  {i.e.,  transplantation  from  another  individual  of  the 
same  species)  is  not  quite  so  successful  and  heteroplasty  (transplanta- 
tion from  a  different  species)  commonly  fails." 

Bums  of  the  Face. — Burns  of  the  face  are  more  common  than  of 
any  other  part  of  the  body;  the  face,  being  uncovered,  is  exposed  to  hot 
vapors  from  machinery,  from  combustible  liquids,  and  from  many  other 
causes.  These  burns  deserve  special  attention;  many  difi&culties  are 
encountered  in  their  treatment  and  striking  deformities  often  result 
from  cicatrization;  one  great  danger  is  that  of  infection  of  the  tissues 
where  they  are  laid  bare  by  abrasion  of  the  skin.  These  burns,  as  in 
general,  vary  in  degree  from  the  most  superficial  to  deep  destruction 
of  the  skin  and  underlying  tissues.  The  pain  of  superficial  burns  can  be 
relieved  by  applying  a  mild  antiseptic  ointment  such  as  boracicacid; 
blebs  and  bullae  should  be  opened  in  a  most  careful  aseptic  fashion. 


INJURIES    AND    DISEASES   OF   THE   FACE    AND    JAW  1 33 

Burns  sufificiently  deep  to  cause  necrosis  or  sloughing  of  the  skin  are 
easily  infected  (  a  useful  and  grateful  dressing  to  the  patient  is  balsam 
Peru  one  part,  castor  oil  eight  parts) ;  their  repair  may  leave  ugly  de- 
forming scars  unless  skin  grafting  is  employed  as  soon  as  granulation  is 
well  established  and  before  cicatrization  has  begun.  Expecially  does 
this  caution  apply  to  burns  in  the  neighborhood  of  the  eyelids,  nose  and 
mouth,  as  contraction  from  cicatrization  not  only  causes  deformity  but 
may  interfere  more  or  less  with  the  functions  of  these  parts.  Burns  by 
contact  with  electric  wires  carrying  a  high  voltage,  and  also  from  X-rays 
(after  the  separation  of  sloughs,  which  is  characteristically  slow)  present 
pale  non-healing  granulating  surfaces  with  poor  nutritional  bases. 
Grafts  placed  either  directly  upon  these  granulations  or  upon  their 
bases  after  curettement,  do  not  "take"  readily  and  repair  is  very 
tedious  and  uncertain. 

Infections  of  the  Face. — A  furuncle  is  a  common,  very  circum- 
scribed, painful  inflammatory  affection  of  the  skin,  the  point  of  entrance 
of  the  infection  usually  being  a  sebaceous  gland  or.  hair  follicle.  The 
pathological  agent  is  the  staphylococcus  pyogenes  aureus.  The 
infection  is  caused  through  some  slight  wound  by  scratching  or  irrita- 
tion, as  in  an  eczema,  acne,  or  sycosis.  The  importance  of  the  lesion 
depends  upon  its  location.  When  upon  the  lips  or  forehead  serious 
consequences  may  follow  as  complications.  It  has  been  observed 
that  furuncles  of  the  face  seem  to  have  a  predilection  for  the  upper  lip 
and  eyebrow.  Upon  the  lip,  because  of  the  interlacing  of  the  muscular 
fibers  and  the  implantation  of  these  fibers  into  the  deep  layers  of  the 
skin,  the  infection  has  diiftculty  in  liberating  itself  externally  and  thus 
extends  along  the  lines  of  least  resistance,  the  lax  submucous  cellular 
tissues,  and  tends  to  invade  neighboring  parts  with  extensive  infiltra- 
tion which  may  break  down  at  numerous  points,  very  similarly  to  a 
carbuncle.  The  great  danger,  however,  is  that  the  infiltration  is 
sometimes  accompanied  by  a  progressive  phlebitis  which  may  spread 
first  from  an  invasion  of  the  facial  vein  to  the  ophthalmic  vein,  and  thence 
to  the  intracranial  sinuses.  An  involvement  of  the  cavernous  sinus 
and  a  fatal  meningitis  may  terminate  what  at  first  may  have  appeared  an 
insignificant  lesion.  When  the  furuncle  attacks  the  eyebrow  there  is 
early  intense  tumefaction  of  the  loose  cellular  tissues  of  the  orbit,  and 
the  dangers  of  intracranial  involvement  must  be  borne  in  mind. 

Treatment. — The  seriousness  of  furuncles  of  the  face  should  be 
anticipated  by  early  radical  treatment.  Release  of  tension  and  ex- 
ternal drainage  must  be  provided  by  free  radiating  incisions — the  core 


134  REGIONAL    SURGERY 

should  be  curetted  out.  Pure  carbolic  acid  can  then  be  used  to  mop 
out  the  core  cavity  and  incisions.  When  seen  early,  the  destruction  of 
the  center  of  the  furuncle  and  the  indurated  surrounding  tissues  by 
means  of  the  actual  cautery  at  a  dull  heat  is  the  best  treatment.  As 
the  cauterized  surfaces  tend  to  interfere  with  drainage,  the  actual  cautery 
should  be  employed  only  when  it  can  be  carried  beyond  the  limits  of 
the  infection.  To  prevent  thrombosis  of  the  facial  veins  they  may  be 
ligated  about  J^  inch  below  the  inner  canthus  of  the  eye,  as 
practised  successfully  by  Bullock. 

Carbuncles  of  the  face  are  relatively  rare  in  comparison  with 
furuncles ;  they  are  caused  in  the  same  way  and  by  the  same  infecting 
staphylococcus  as  the  furuncle.  They  have  like  characteristics 
except  that  there  is  greater  extension  of  infiltration  of  adjacent  tissues 
with  multiple  foci  of  necrosis  and  gangrene  of  the  tissues  surrounding 
the  infected  foci.  In  the  beginning,  a  furuncle  and  carbuncle  have 
such  similar  appearances  that  they  can  hardly  be  differentiated.  A 
carbuncle,  from  the  beginning,  is  more  painful,  and  there  is  apt  to  be  a 
chill  and  fever.  Soon,  however,  the  distinctive,  spreading,  dusky  oedema, 
with  pustules  appearing  in  its  central  area — each  pustule  being  a  focus 
of  necrosis — identifies  the  carbuncle. 

The  treatment,  which  is  often  emolient  and  tentative  when  car- 
buncle's appear  upon  other  parts  of  the  body  than  the  face,  should,  in 
the  latter  location,  be  as  thorough  and  radical  as  recommended  for 
furuncles;  free  incisions  should  be  made  and  curettage  done,  followed 
by  the  application  of  pure  carbolic  acid,  or  preferably  the  actual 
cautery.  A  properly  applied  actual  cautery  will  cause  the  infected 
area  to  shrink  or  contract  to  a  remarkable  degree. 

Malignant  Pustule ;  Anthrax;  Wool -sorter's  Disease ;  Charbon  are 
terms  applied  to  a  disease  which  may  be  quite  similar  to  carbuncle  but 
which  is  caused  by  a  different  germ,  the  anthrax  bacillus.  Although 
not  a  common  disease  in  America  it  is  occasionally  met.  The  infec- 
tion is  most  often  seen  among  workers  with  animals  or  hides.  The 
anthrax  bacillus  produces  a  lesion  very  similar  to  a  carbuncle.  In  the 
beginning  it  appears  as  an  irritating  papule  with  a  purple  center  and 
red  base.  The  papule  rapidly  changes  to  a  vesicle  containing  bloody 
serum,  the  surrounding  redness  and  induration  increases,  the  vesicle 
bursts  and  a  yellowish-black  scab  forms,  surrounded  by  a  crop  of 
vesicles  similar  to  the  beginning  central  one.  The  surrounding  vesicles 
appear  elevated  above  the  central  scab;  there  is  an  extending,  dark, 
bluish,  angry-looking  infiltration;  crops  of  vesicles  form  as  the  infiltra- 


INJURIES    AND    DISEASES    OF    THE    FACE    AND  JAW  135 

tion  extends,  and  gangrene  may  develop;  neighboring  lymph  glands 
enlarge  but  do  not  suppurate.  Although  in  some  instances  it  may  be 
difficult  to  differentiate  between  malignant  pustule  and  carbuncle  on 
the  face,  a  bacteriological  examination  of  the  vesicle  contents  will 
positively  clear  up  the  diagnosis.  Great  pain  is  not  a  feature  of  mahg- 
nant  pustule.  Should  the  anthrax  bacillus  be  found  in  the  blood,  a 
most  serious  prognosis  is  obligatory  as  this  is  said  to  almost  always 
presage  death.     The  bacillus  is  found  in  the  blood  of  all  fatal  cases. 

Treatment. — Any  wound  or  vesicle  slightly  suspicious  of  anthrax, 
appearing  on  the  face,  as  on  other  parts  of  the  body,  should  be  deeply 
cauterized  with  the  actual  cautery.  If  a  malignant  pustule  has  formed, 
not  only  should  the  pustule  area  be  destroyed  with  the  actual  cautery, 
but  the  red  infiltrated  area  likewise.  The  cauterizing  iron  should  be 
at  a  dull  red  heat,  the  object  being  not  only  to  destroy  all  visibly  affected 
tissues,  but  likewise  to  extend  the  heat  from  the  iron  beyond  the  cau- 
terized area,  so  that  any  bacilli  immediately  without  the  cauterized 
zone  may  be  killed  or  inhibited  from  activity.  Excision,  radiating 
incisions,  curettage  and  the  after-use  of  pure  carbolic  acid,  have  been 
successfully  employed.  In  addition  the  carbohc  acid  may  be  injected 
into  the  infected  tissues.^  The  most  painstaking  care  should  be  exer- 
cised during  the  progress  of  the  case,  against  infection  of  attendants.  The 
patient  must  be  isolated;  everyone  coming  into  contact  with  the  subject 
must  be  protected  by  the  usual  operating-room  coverings  for  the  body, 
head,  face  and  hands.  Dressings  must  be  burned  and  extra  care  taken 
in  the  sterilization  of  all  paraphernalia  immediately  after  each  dressing. 
Not  only  should  the  room  which  was  occupied  by  the  patient  be 
carefully  scrubbed  and  fumigated,  but  all  bedding  burned  as  used. 

Facial  Adenitis. — An  important  infection  has  recently  been  brought 
to  our  attention  by  Lenormant — that  of  the  facial  glands.  In  about 
60  per  cent.'  of  individuals  three  groups  of  glands  are  found  on  the 
sides  of  the  face  (Fig.  82)  and  these  at  times  are  the  subjects  of  infection, 
either  acute  or  chronic.  Mascagni  first  described  and  figured  these 
glands.  But  little  attention  was  paid  to  them  until  recently,  when  other 
investigators  in  France  and  Germany  pointed  out  their  clinical  and 
pathological  importance.  The  groups  of  glands  are  divided  according 
to  their  location:  First,  an  inferior  maxillary  group  formed  of  two  or 

^  First  reliance  must  be  placed  upon  the  local  destruction  of  the  infection  by  the  use  of 
the  actual  cautery  and  carbolic  acid.  The  serum  treatment  must  never  be  neglected; 
Scalvo's  serum,  in  40  cc.  doses,  should  be  injected  subcutaneously,  preferably  in  different 
places  in  the  abdominal  wall,  or  lo  cc.  doses  may  be  given  intravenously.  The  serum  is 
harmless,  and  has  been  reported  to  have  been  followed  by  recovery  in  desperate  cases. 


136 


REGIONAL    SURGERY 


three  glands  situated  on  the  external  surface  of  the  inferior  maxilla  in 
front  of  the  masseter  muscle,  between  the  facial  artery  and  vein.  This 
group  is  sometimes  connected  with  an  inframaxillary  ganglion  situated 
a  cheval  on  the  inferior  border  of  each  surface  of  the  inferior  maxillary 
bone.  A  middle  group  is  situated  upon  the  buccinator,  one  part  of 
which  (the  anterior)  is  found  not  far  from  the  angle  of  the  mouth  be- 
tween the  facial  artery  and  vein;  the  other  (posterior),  near  the  point 


Fig.  82.- 


-Facial  glands,     a.  Infra-maxillary  gland;  b,  supra-maxillary  glands;  c  and  d, 
buccinator  glands;  e  and/,  malar  glands.     (Buchbinder.) 


where  Stenson's  duct  perforates  the  buccinator.  A  third  group  (the 
superior  or  malar)  is  located  on  the  malar  process  of  the  superior  max- 
illary bone  or  upon  the  malar  bone.  The  superior  and  middle  groups 
receive  lymphatics  from  the  nose,  upper  lip,  the  temple,  the  eyelids  and 
the  cheeks,  the  superior  alveolus  with  its  teeth,  the  tonsils,  the  pillars 
of  the  fauces,  and  the  parotid  gland.  The  maxillary  glands  receive 
lymphatics  from  all  of  these  locations  and  also  from  the  lower  lip.     The 


INJURIES    AND   DISEASES    OF    THE    FACE    AND    JAW  I37 

facial  groups  of  glands  may  be  the  seat  of  any  glandular  affection,  acute 
or  chronic,  following  an  injury  or  infection  to  a  cutaneous  or  mucous 
area  drained  by  lymphatics  into  these  glands.  Any  of  the  locations 
noted  above  can  be  the  port  of  infection.  The  most  common  infection 
is  from  dental  caries,  more  particularly  of  the  upper  molars;  infection 
in  these  glands  is  common  among  scrofulous  children. 

Trendel,  of  the  Tubingen  Clinic,  has  studied  the  histories  of 
87  cases  of  inflammation  of  the  facial  ganglions;  among  these  were  a 
number  of  personally  observed  cases.  It  was  noted  chiefly  that  when 
the  adenitis  is  acute  there  is  more  or  less  pain  upon  movement  of  the 
jaw;  the  cheek  is  red  and  swollen  as  is  sometimes  observed  in  inflam- 
mation of  the  roots  of  teeth  and  the  gums.  Fluctuation,  when  present, 
is  detected  between  two  fingers,  the  one  placed  within  the  mouth,  the 
other  outside;  in  this  way  the  inflammation  can  be  proven  to  be  inde- 
pendent of  the  maxilla  itself.  There  may  be  general  symptoms  of 
septic  absorption,  such  as  chill  and  fever.  Usually  when  not  inter- 
fered with,  the  suppuration  evacuates  itself  externally  through  the  skin 
rather  than  into  the  mouth.  When  the  infection  is  chronic,  the  changes 
are  slow  and  insidious.  When  the  infection  comes  from  a  tooth,  a 
smooth,  roundish,  movable  swelling  develops  upon  the  external  surface 
of  the  maxilla.  It  is  only  slightly  painful,  but  may  soften,  suppurate, 
adhere  to  the  skin,  and  open  externally  with  possibly  a  small  fistula 
resulting.  Tuberculous  infection  of  these  glands  sometimes  occurs;  its 
history  is  quite  analogous  to  the  chronic  form.  In  malignant  disease 
affecting  the  parts  of  the  face  drained  by  these  glands,  they  act  as  do 
lymphatics  and  glands  in  other  parts  of  the  body.  It  is  said  that  only 
one  case  of  malignancy  has  been  observed  having  its  origin  in  the  facial 
glands.     (Bourgeois-Lenormant.) 

Tuberctilosis  of  the  face,  the  different  forms  of  lupus,  belong  to  the 
realm  of  skin  diseases. 

Actinomycosis  of  the  Face. — Location  of  Election . — Actinomycosis  is 
found  more  frequently  on  the  face  than  elsewhere.  As  in  the  same 
infection  of  the  jaws,  the  infecting  organism  gains  entrance  through  the 
mucosa,  from  bits  of  straw,  stems  of  vegetables,  etc.,  in  masticating  or 
holding  them  in  the  mouth.  An  existing  ulceration  may  be  the  site  of 
inoculation.  The  disease  is  found  on  the  cheek,  over  the  inferior 
maxilla,  or  more  often  on  the  temporo-maxillary  part  of  the  face;  it  is 
always  chronic,  usually  not  continually  painful,  but  may  have  crises  of 
pain.  Early  in  its  history  there  is  muscular  spasm  (trismus)  which  is 
characteristic  and  continues  during  the  history  of  the  disease.     Given 


138  REGIONAL   SURGERY 

a  tumefaction  upon  the  side  of  the  face,  neither  of  a  bony  hardness  nor 
cedematous  nor  fluctuating,  with  normal  external  skin  or  mucous 
covering  as  it  projects  into  the  mouth,  the  swelling  of  the  soft  parts 
independent  of  any  apparent  swelling  of  the  bone,  and  an  absence  of 
glandular  involvement — all  this,  added  to  the  attacks  of  pain  and  tris- 
mus, should  render  a  diagnosis  of  actinomycosis  probable.  Later, 
when  softening  and  opening  of  the  center  of  the  inflamed  areas  occurs, 
the  characteristic  discharge  of  actinomycosis,  with  its  parasite,  is 
present.     One  or  several  fistulous  openings  may  form. 

Treatment. — Iodide  of  potassium  in  large,  increasing  doses  is  the 
main  reliance  in  treatment.  Surgical  intervention  should  be  limited 
to  the  period  of  fistulous  formation  and,  then  it  should  be  restricted  to 
favoring  free  drainage. 

The  Orbit. — The  most  common  contusion  of  the  orbit,  "black  eye," 
usually  results  from  the  blow  of  a  fist,  but  may  follow  any,  even  an 
apparently  slight,  injury.  The  looseness  of  the  orbital  cellular  tissue 
admits  of  easy  rupture  of  its  blood-vessels  with  extravasation  of  blood, 
and  this  follows  so  rapidly  that  within  a  few  hours  of  the  injury  very 
distinct  ecchymosis  forms;  there  may  be  subconjunctival  ecchymosis 
also.  All  degrees  of  swelhng  occur,  up  to  the  complete  closure  of  the 
eye.  Fractures  of  the  orbital  ridges  and  the  anterior  fossa  of  the  skull 
may  be  followed  by  hemorrhage  into  the  eyelids,  conjunctiva  and  orbital 
cellular  tissue,  but  the  extravasation  does  not  come  on  within  the  first 
few  hours  as  in  simple  "black  eye;"  it  gradually  makes  its  appearance 
during  the  24  to  72  hours  following  the  injury. 

Treatment. — Hot- water  compresses  apphed  for  several  hours  followed 
by  a  firm  bandage,  preferably  an  elastic  one  put  on  over  a  sufiicient- 
sized  wad  of  absorbent  cotton,  will  tend  to  limit  extravasation  and 
hasten  absorption  of  the  effused  blood. 

Wounds  of  the  Eyelids. — Wounds  of  the  eyelids  are  not  uncom- 
mon and  are  of  importance  according  to  their  depth  and  direction. 
When  superficial  and  in  the  direction  of  the  fibers  of  the  orbicularis 
muscle,  they  do  not  gape  and  they  heal  kindly.  Vertical  wounds  gape 
widely.  Horizontal  wounds  may  require  suturing,  but  this  is  usually 
unnecessary  unless  the  wound  is  deep  and  the  levator  palpebrae  supe- 
rioris  tendon  is  divided.  In  such  an  instance  the  divided  ends  should 
be  sewed  together  with  fine  catgut  and  the  skin  wound  closed  with 
a  few  interrupted  stitches.  Deep  vertical  wounds  require  not  only 
buried  catgut  sutures  but  in  addition  supporting  silk  stitches  passed 
deeply  and  at  some  distance  from  the  wound  edge  so  as  to  render  good 


INJURIES    AND    DISEASES    OF    THE    FACE    AND    JAW 


139 


support  to  the  buried  sutures,  as  there  is  apt  to  be  considerable  swell- 
ing unless  the  inflicting  instrument  was  a  keen-cutting  one. 

Tumors  of  the  Eyelids. — The  tumors  of  the  Hds  which  are  of  especial 
interest  to  the  general  surgeon  are  the  angiomata,  sarcomata,  and  car- 
cinomata.  The  angiomata  are  either  of  the  teleangiectatic  or  cavernous 
type;  they  are  usually  observed  shortly  after  birth  and  may  grow 
rapidly.  Should  they  show  this  tendency,  early  removal  is  desirable. 
This   can   be   accomphshed   with    the   galvano-cautery   needle.     The 


Fig.    83. — Enlarged,   rapidly  growing       Fig.  84. — The  same  case  after  treatment  by 
angioma  of  the  upper  lid  and  forehead.        injection  with  alcohol.     {By  Dr.  H.  B.  Lemcre.) 


cavernous  tumors  should  either  be  destroyed  by  electrolysis  or,  if 
small,  they  may  be  excised.  If  large  and  growing  rapidly  (as  in  Fig. 
83)  they  are  best  destroyed  by  injections  of  absolute  alcohol,  30 
to  40  minims  injected  at  intervals  of  from  one  week  to  two  months; 
Fig.  84  shows  the  result  of  this  treatment. 

Sarcoma  of  the  lids  is  usually  of  the  melanotic  type  (melano- 
sarcoma) ;  it  is  chiefly  found  in  children  and  young  people  but  may  be 
found  at  any  age;  its  occurrence  is  rare.  The  growth  begins  as  an 
elastic  circumscribed  swelling  in  the  connective  tissue.  As  it  infiltrates 
the  skin,  its  rnelanotic  color  becomes  apparent.  The  skin  breaks  down, 
forming  an  ulcer  with  bluish-black  edges  and  base.     The  growth  may 


I40  REGIONAL    SURGERY 

extend  to  the  globe  and  orbital  tissues.     Early  radical  removal  is  the 
only  treatment  (Fig.  85). 

Carcinoma  of  the  lid  is,  as  a  rule,  of  the  slow-growing  epithelioma 
type  of  ulcer;  the  base  and  edges  are  irregular  and  infiltrated,  repair 
taking  place  at  one  part  while  the  edge  breaks  down  and  the  ulcer 


Fig.  85. — Melano  sarcoma  of  the  lid.     (Patient  of  Dr.  H.  Gifford,  operated  on  successfully.) 

spreads  at  another  part.  The  X-ray  and  radium  hold  the  first  place  in 
the  treatment  of  these  ulcers,  while  escharotics  are  also  useful.  These 
methods  of  treatment  are  preferable  to  the  knife  which,  to  be  success- 
ful, must  cut  wide  of  the  ulcer  edges,  and  plastic  work  may  be  necessary 
to  restore  a  proper  covering  for  the  eye. 


INJURIES    AND    DISEASES    OF    THE    FACE    AND    JAW  141 

Punctured  "Wounds  through  the  Orbit. — Clinically,  these  injuries 
seldom  occur  except  through  the  orbital  plate  of  the  frontal  bone.  A 
very  few  cases  have  been  reported  of  the  puncturing  instrument  entering 
through  the  nostrils.  An  instrument  may  be  driven  through  the  skull 
at  any  part  and  wound  the  brain.  A  considerable  variety  of  instru- 
ments have  been  known  to  penetrate  the  brain  by  way  of  the  thin 
orbital  plate  of  the  frontal  bone,  the  most  common  having  been  umbrella 
sticks,  canes,  pieces  of  wood,  narrow-bladed  instruments  of  warfare, 
etc.  The  eye  not  uncommonly  escapes  injury  when  the  entering 
instrument  fractures  the  orbital  plate  near  the  superior  orbital  fissure. 
In  such  cases,  the  wound  first  passes  through  the  upper  eyelid.  A  part 
of  the  puncturing  instrument  may  remain  in  the  brain.  The  injury 
to  the  brain  is  usually  confined  to  the  frontal  lobes,  but  may  involve 
other  parts.  If  the  brain  is  punctured  through  the  optic  foramen,  the 
eye  is  almost  certainly  injured,  and  the  optic  nerve  is  necessarily 
crushed  or  divided  unless,  perchance,  the  puncturing  instrument  is  of 
very  small  diameter,  like  a  hatpin.  Besides  any  injury  to  the  eye  which 
may  complicate  these  accidents,  the  main  danger  lies  in  the  brain  lesion; 
not  so  much  usually  from  the  immediate  destruction  of  brain  tissue 
as  from  secondary  inflammatory  processes. 

Hemorrhage  may  be  sufficient  to  produce  dangerous  pressure  symp- 
toms, but  this  will  hardly  occur  unless  the  injury  is  through  the  floor  of 
the  orbit  toward  the  vessels  at  the  base  of  the  brain. 

Treatment. — The  treatment  of  these  injuries  should  be  directed 
toward  an  exposure  of  the  injured  parts  sufficiently  extensive  to  enable 
the  surgeon  to  carefully  examine  for  the  presence  of  a  foreign  body, 
when,  from  the  history  of  the  case,  such  a  body  may  have  remained  in 
the  wound.  The  surgeon  should  not  limit  his  interference  until  he  has 
cleared  a  passage  for  careful  inspection  and  drainage  of  the  injured 
brain.  Although  it  may  be  necessary  to  boldly  open  up  the  skull  in 
front  of  and  above  the  track  of  the  wound,  usually  it  will  suffice  if, 
after  shaving  the  eyebrow  and  using  the  usual  aseptic  precautions,  the 
orbital  plate  of  the  frontal  bone  is  exposed  by  making  a  free  curved 
incision  along  the  upper  edge  of  the  orbit  down  to  the  bone,  separating 
the  loose  cellular  tissue,  and  depressing  the  globe  with  a  small  flat 
retractor.  By  this  means  sufficient  space  will  be  secured  for  the 
exposure  of  the  wound.  With  small  chisels  the  opening  through  the 
bone  is  enlarged  sufficiently  to  explore  the  wound  and  provide  for 
drainage.  The  accompanying  photograph  (Fig.  86)  is  of  a  child  who 
had  fallen  upon  a  rusty,  dirty  button-hook  with  which  it  had  been 


142 


REGIONAL   SURGERY 


playing.  The  hook  had,  in  some  manner,  rotated  so  that  it  was 
necessary  to  remove  considerable  bone  before  it  was  extracted.  The 
writer  followed  the  practice  just  recommended  and  recovery  was 
entirely  satisfactory.  Should  the  brain  be  punctured  through  the 
optic  foramen,  the  eyeball  must  be  removed  to  admit  of  proper  explora- 
tion and  drainage.  In  such  a  case,  even  if  the  globe  of  the  eye  is  not 
injured,  the  optic  nerve  probably  is,  and  in  any  case  it  is  better  to 
sacrifice  the  eye  than  to  invite  secondary  inflammatory  conditions  in 
the  orbit  and  maybe  in  the  brain.  A  good  general  rule  would  be  that, 
in  all  cases,  the  bottom  of  the  wound  should  be  explored  and  drained 
by  the  most  direct  route,  preserving  the  integrity  of  an  uninjured  eye- 
ball when  possible.  If  the  eyeball  is  wounded  and  probably  infected, 
it  should  be  removed.  The  inflammatory  sweUing  of  the  loose  con- 
nective tissues  of  the  orbit  is  a  source  of  great  danger.     The  swelling 


Fig.  86. — Punctured  wound  of  the  brain  through  the  orbital  plate  of  the  frontal  bone. 
(From  a  patient  in  the  Clarkson  Hospital.) 

interferes  with  drainage,  and  infection  may  pass  along  the  track  of  the 
wound  to  the  brain.  When  practicable,  the  counsel  and  assistance  of 
an  expert  oculist  should  always  be  sought  in  the  treatment  of  these 
comphcated  injuries.  In  those  rare  wounds  of  the  brain  through  the 
nostrils,  the  base  of  the  brain  should  be  freely  exposed  by  making  an 
opening  through  the  frontal  bone.  Most  painstaking  antisepsis  must 
be  employed  so  as  to  limit  probable  infection  derived  from  the  nasal 
cavity. 

Abscess  of  the  Orbit  (Cellulitis). — Infection  of  the  cellular  tissue  of 
the  orbit  may  result  not  only  from  injury  and  the  presence  of  foreign 
bodies,  but  also  from  inflammations  having  their  starting  point  about 
the  teeth  or  upper  jaw,  the  nasal  fossae  and  the  neighboring  sinuses.  It 
is  sometimes  a  complication  of  facial  erysipelas;  it  also  maybe  second- 
ary to  infections  of  the  conjunctiva  and  eyeball  itself  (Fig.  87). 

Symptoms. — There  is  marked  swelling  and  oedema  of  the  conjunctiva 


INJURIES    AND    DISEASES    OF    THE    FACE    AND    JAW 


143 


and  eyelids;  as  the  inflammation  progresses  the  lids  become  a  dusky  red, 
and  this  signifies  the  beginning  or  presence  of  suppuration,  which  is  the 
usual  termination.  In  most  severe  cases  the  constitutional  symptoms 
are  marked,  with  rigors,  high  temperature,  rapid  pulse  and  severe 
pain. 

Treatment. — As  the  dangers  to  be  feared  are  first,  spread  of  the 
infection  to  the  meninges,  and  second,  destruction  of  the  eye,  early 
interference  is  indicated;  this  consists  in  making  an  incision  through  the 


Fig.  87. — Orbital  cellulitis,  secondar}-  to  ethmoiditis.     (Patient  of  Dr.  H.  Gifford.) 


conjunctiva  at  the  palpebral  fold,  and  passing  the  knife  backward  in 
such  a  manner  as  not  to  injure  the  globe,  the  idea  being  to  establish 
drainage  as  early  as  possible.  In  more  advanced  cases  where  there  is 
great  swelling,  it  is  wiser  to  make  the  incision  through  the  lid  at  the 
orbital  margin,  and  then  to  introduce  a  suitable-sized  curved  forceps 
in  such  a  way  as  to  avoid  injury  to  the  globe.  After  pus  has  been 
reached  the  forceps  blade  is  opened  as  the  instrument  is  withdrawn, 
thus  enlarging  the  drainage  tract,  which  should  be  kept  open  by  proper- 
size  tubing.      Hot  boracic  fomentations  should  be  used  and  no  pains 


144 


REGIONAL   SURGERY 


spared  to  keep  the  drainage  free.     Infections  of  the  eye  itself  call  for 
evacuation  of  the  globe,  and  possibly  later  enucleation. 

Tumors  of  the  Orbit. — Tumors  of  the  orbit  arise  from  the  orbital 
tissues  themselves,  or  from  the  bony  walls  or  neighboring  sinuses, 
involving  the  orbit  secondarily.  When  the  tumor  is  fluid  its  origin  is 
usually  from  the  frontal  sinus  or  the  ethmoid.  The  fluid  is  either 
mucus  or  muco-pus.     Fig.  88  illustrates  a  benign  tumor  of  the  orbit. 


Fig.  88. — Frontal  mucocele  of  three  years'  standing,  causing  dislocation  of  the  eyeball. 
[British  Journal  of  Surgery,  April,  1914.) 

having  its  origin  in  the  frontal  sinus.  Distinct  egg-shell  crackling 
could  be  obtained  over  the  surface  of  the  tumor.  This  identified  its 
cystic  nature.  It  was  operated  on  successfully.  Solid  tumors,  originat- 
ing in  the  soft  tissues  of  the  orbit,  are  almost  always  malignant.  In 
children  they  are  exceedingly  malignant  and  commonly  gliomata; 
they  may  be  bilateral.  In  older  people  they  originate  in  any  part  of  the 
globe.  When  the  tumor  begins  in  the  pigmented  structure  of  the  globe 
it  takes  on  melanotic  characteristics. 

Exophthalmos  is  usually  present  and  the  direction  of  the  protrusion 


INJURIES    AND    DISEASES    OF    THE.  FACE    AND    JAW 


145 


is  generally  away  from  the  location  of  the  tumor  (Fig.  89) ;  there  is 
limitation  of  motion  and  some  ptosis,  and  diplopia  will  probably  be 
present  if  there  is  much  displacement.  The  intraocular  tension  is  in- 
creased, the  pupil  is  dilated,  and  blindness  follows;  the  lids  become 
oedematous.     Solid   tumors  cannot  be  pressed  back  into  the  orbit; 


Fig.  89. — Solid  tumor  of  the  eye — glioma.     Exopthalmos;  tumor  located  towards  nasal 
side  of  orbit.     {H.  Giford.) 


cystic  tumors  can,  to  a  slight  degree.  Because  of  the  inability  of  the 
lids  to  protect  the  cornea,  ulceration  may  take  place.  A  solid  tumor 
arising  from  the  bony  walls  of  the  orbit  is  an  osteoma;  it  occurs  usually 
in  persons  under  25  years  of  age,  has  a  sessile  base  and  produces  eye 
symptoms  according  to  its  size  and  location.     This  tumor  seldom  be- 


146  REGIONAL    SURGERY 

comes  malignant.  Numerous  kinds  of  cysts  are  found  in  the  cellular 
tissue  of  the  orbit,  among  them  a  congenital  encephalocele  passing 
from  the  brain  through  the  suture  between  the  ethmoid  and  frontal 
bones.  Its  growth  is  rapid;  it  may  or  may  not  pulsate;  the  eye  be- 
comes displaced.  A  pulsating  orbital  tumor  is  commonly  an  aneurism 
of  the  ophthalmic  artery.  Often  the  pulsation  is  caused  by  an  arterio- 
venous aneurism,  or  a  connection  between  the  carotid  and  the  cav- 
ernous sinus.  These  tumors  must  be  differentiated  from  the  tumors 
of  a  malignant  type  rich  in  blood-vessels — telangiectic  sarcomas.  As 
the  aneurism  grows,  exophthalmos  develops  and  one  can  see  and  feel 
a  distinct  systolic  pulsation.  The  patient  hears  the  purr  of  the  aneu- 
rism (D3'ball).  Compression  of  the  common  carotid  causes  a  disap- 
pearance of  the  pulsation. 

Treatment. — If  a  pulsating  orbital  tumor  is  of  rapid  growth  and  the 
discomfort  is  sufficient  to  justify  the  risk,  the  internal  carotid  on  the 
same  side  should  be  tied.  A  cure  must  not  be  promised  as  the  symp- 
toms may  return;  should  the  recurrence  take  place,  the  remaining 
internal  carotid  may  be  tied.  An  osteoma  should  be  exposed  by'  a 
suitable  incision  and  removed,  after  chiseling  through  its  base.  The 
congenital  encephalocele  is  inoperable;  life  is  usually  terminated  in  the 
first  four  to  eight  months.  The  removal  of  gliomata  in  children  is 
usually  followed  by  recurrence,  even  when  operated  upon  early.  All 
tumors  of  the  orbit  should  be  removed  as  early  as  possible. 

Tumors  of  the  Face. — The  face  is  a  favorite  seat  for  epitheliomata; 
warts,  moles,  chronic  inflammations  or  ulcerations  are  the  chief  pre- 
disposing factors.  It  is  sometimes  difficult  to  recognize  the  beginning 
of  a  carcinomatous  growth.  The  formation  of  crusts  which  reappear 
when  removed  from  a  granular  bleeding  surface,  the  gradual  extension 
of  the  ulceration  with  indurated  and  raised  edges  should  always  arouse 
the  suspicion  of  malignancy.  The  involvement  of  the  regional  lymph- 
atic glands  may  be  an  early  or  late  complication,  depending  upon  the 
degree  of  malignancy  of  the  primary  growth. 

Treatment. — As  in  all  other  malignant  affections,  a  timely  diagnosis 
and  a  radical  excision  of  the  diseased  area,  including  a  liberal  margin 
of  adjoining  tissues,  offers  the  only  hope  of  a  permanent  cure.  Rapidly 
growing  epitheliomata  with  metastasis  to  the  local  glands,  although  not 
flatteringly  hopeful  as  to  operative  cure,  should  be  excised,  removing 
as  well  as  possible  all  of  the  growth  and  glands  together,  and  cauterizing 
with  the  actual  cautery  the  edges  and  bases  of  the  wound.  Cures  by 
the  X-ray  and  radium  of  chronic  slow-growing  epitheliomata  are  from 


INJURIES    AND   DISEASES    OF    THE    FACE    AND    JAW 


147 


time  to  time  reported*  and  the  intelligent  use  of  escharotics  certainly 
has  a  place  in  the  treatment  of  the  less  malignant  types  of  growth. 

Carcinoma  of  the  Lip. — Cancer  of  the  lower  lip  is  frequently  ob- 
served; the  upper  lip  is  seldom  the  seat  of  a  primary  cancer  and  women 
are  singularly  free  from  this  form  of  cancer. 

As  is  the  case  elsewhere,  cancer  of  the  lip  follows  some  irritation, 
A  pressure  irritation  or  blistering  in  a  tobacco  smoker  from  a  hot  pipe- 
stem,  is  a  well-recognized  cause.  The  disease  occurs  in  people  at  or 
beyond  middle  age;  usually  it  begins  on  one  side,  at  the  muco-cutaneous 
border,  as  a  blister  or  burn;  there  is 
a  "small  depressed  area,  dark  in  color 
and  of  leathery  consistency.  This 
dark  area  cannot  be  picked  off  as  u 
scab."  Later  a  scab  forms  which  can 
be  picked  off  leaving  a  slightly  bleed- 
ing surface.  Induration  begins  to 
develop  around  and  beneath  the  scab, 
and  sooner  or  later  an  ulcer  forms. 
This  ulcer  may  heal  and  again  break 
down  with  a  tendency  to  slowly 
spread.  After  the  ulcer  forms,  it 
may  spread  rather  rapidly  until  a 
greater  or  less  part  of  the  lip  is  in- 
volved, sometimes  extending  around 
the  angle  of  the  mouth  and  attacking 
the  upper  lip  (Fig.  90). 

Usually  within  three  months  from 
the  commencement  of  the  formation 
of  the  ulcer  the  submental,  submaxil 
lary  and  cervical  glands  become  in- 
fected with  cancer,  the  involvement 

occurring  in  the  order  named,  although  they  may  not  be  palpable. 
On  the  other  hand,  the  glands  may  early  enlarge  from  septic  absorp- 
tion, before  cancer  infection  has  invaded  them. 

Although  the  progress  of  the  formation  of  the  ulcer  may  be  very 
slow,  sometimes  lasting  a  year  or  longer,  yet  after  the  ulcer  is  developed 
the  glands  are  already,  almost  without  exception,  invaded  by  the  cancer 
germs.  As  the  ulcer  spreads,  it  eats  into  and  destroys  the  lip,  coverings 
of  the  chin,  and  often  there  is  a  large,  foul,  ulcerating  mass,  involving 
the  floor  of  the  mouth,  the  infected  glands,  and  even  the  lower  jaw. 


Fig.  90. — Carcinoma  of  the  lower 
lip,  extending  around  the  angle  and  at- 
tacking the  upper  lip. 


148 


REGIONAL   SURGERY 


Death   occurs   from   pain  and  exhaustion,  or  from   hemorrhage;  the 
disease  lasts  from  commencement  to  end  three  and  even  five  years. 

Cancer  of  the  lip  can  hardly  be  mistaken  for  any  other  lesion.  In 
the  earliest  precancerous  stages  the  lesion  is  local.  Out  of  200 
cases  (Bloodgood,  Surgery  Gynecology  and  Obstetrics,  April,  19x4), 
15  were  microscopically  found  to  be  benign.  Warts,  either  benign 
or  maHgnant,  may  grow  upon  the  lips;  they  follow  injuries  such  as  a 
razor  cut,  the  habit  of  frequently  biting  the  lips,  smoker's  burn,  wounds 
of  some  kind,  blisters,  etc.  The  malignant  warts  are  larger  than  the 
benign  and  usually  ulcerate  both  at  the  surface  and  at  the  base.  "A 
wart  on  the  lower  lip  larger  than  the  end  of  the  index-finger  was  always 
microscopically  malignant,  but  smaller  warts  have  been  microscopically 


Fig.  91. —  {Grant.) 


Fig.  92. — {Grant.) 


maHgnant."  A  cancerous  ulcer  of  the  lip  can  hardly  be  mistaken  for  any 
other  lesion  although  chancre  of  the  lip  must  be  reckoned  with;  how- 
ever, the  fact  that  chancre  may  occur  at  any  age,  the  history,  the  acute 
character  of  the  ulcer,  the  early  lymphatic  involvement,  the  appearance 
of  secondary  symptoms,  the  discovery  of  the  spirochseta  pallida,  the 
positive  Wassermann  reaction  after  the  appearance  of  the  secondary 
symptoms,  and  the  early  healing  of  the  ulcer  under  the  administration 
of  antisyphilitic  remedies,  including  Salvarsan,  will  differentiate  the 
ulcer.  Gumma  of  the  lip  is  rare;  its  rapid  disappearance  under  the 
administration  of  iodide  of  potassium  and  mecrury  alone  or  with  Salvar- 
san, positively  differentiates  it  from  cancer — besides,  when  not  irri- 
tated there  is  an  absence  of  pain  and  glandular  enlargement. 

Treatment. — The  successful  treatment  of  this  curable,  common  form 
of  cancer  depends  upon  two  things:  one,  the  earliness  with  which  the 


INJURIES    AND    DISEASES    OF    THE    FACE    AND    JAW 


149 


lesion  is  detected,  the  other,  the  thoroughness  with  which  it  is  removed. 
Experience  demonstrates  that  although  the  lesion  may  be  detected 
early  (within  three  months  of  its  beginning)  and  the  growth,  with  a 
wide  margin  of  normal  appearing  tissue,  be  removed,  yet  later  glandular 
involvement  develops,  proving  that  even  in  seemingly  local  lesions  it  is 
not  wise  to  refrain  from  the  removal  of  the  glands.  Bloodgood  reports 
one  late  infection  (after  five  years)  out  of  10  cases  in  which  the  lesion 
was  less  than  three  months  old.  Excision  of  the  lesion  of  the  lip  and 
glands  in  which  there  was  no  apparent  metastasis  in  the  glands,  resulted 
in  twenty  cures  among  21  cases.  On  the  other  hand,  when 
the  same  procedure  was  carried  out,  there  being  present,  however, 
a  metastasis  in    the  glands,  out  of   12  cases  there  were  six  cures — 


{Grant.) 


Fig.  94. — {Grant 


recurrence  in  the  glands  of  the  neck  took  place  in  five,  and  in  one  the 
recurrence  was  local.  Of  the  five  gland  recurrences,  there  was  only  one 
cured  by  farther  operation. 

All  of  this  goes  to  demonstrate  a  rule  of  practice  from  which  there 
should  be  no  possible  exception — radical  removal  of  the  primary  lesion 
and  also  of  the  glands  in  direct  line  for  metastatic  infection.  Any 
habit  or  occupation  which  has  caused  to  form  a  recurrent  local  lesion 
upon  the  lower  lip,  which  is  demonstrable,  and  this  lesion  disappears 
upon  the  giving  up  of  the  irritating  cause,  need  only  mean  a  warning 
that  a  persistence  in  the  habit  of  irritation  may  result  in  cancer  at  the 
site  of  irritation.  A  little  lesion  or  ulcer,  if  it  does  not  disappear  after 
removing  the  cause  of  irritation  and  employing  hland  local  treatment, 
should  receive  careful  consideration  as  to  operative  treatment.  Caustics 
and  irritants  of  all  kinds  are  more  than  contraindicated;  they  are 
dangerous. 


150  REGIONAL   SURGERY 

Operation. — Numerous  incisions  have  been  devised  for  the  removal 
of  the  growth  and  for  the  excision  of  the  submaxillary  lymph  glands. 
The  operation  that  best  meets  these  indications  and  at  the  same  time 
admits  of  closure  of  the  incisions  so  as  to  give  a  useful  and  relatively 
natural  appearing  mouth  is,  in  the  judgment  of  the  writer,  that  devised 
by  W.  W.  Grant  of  Denver,  Col.  "Two  perpendicular  incisions 
are  made  on  each  side  of  the  growth,  connected  by  a  straight  transverse 
incision  at  the  base,  which  is  usually  about  the  crease  between  the  chin 
and  lip.  This  leaves  a  quadrangular  space  to  be  filled  by  flaps.  An 
incision  is  now  made  from  each  inferior  angle  of  the  wound,  obliquely 
downward  and  backward  beneath  the  maxilla,  on  a  line  about  equi- 


FiG.  95. —  {Grant.) 

distant  between  its  angle  and  the  apex  of  the  chin  or  symphysis.  (Figs. 
91,  92,  93,  and  94.)  Its  further  extension  is  measured  by  the  extent 
of  lip  removed  and  the  glandular  involvement.  All  the  submaxillary 
glands  are  removed  through  these  incisions  except  the  submental, 
which  may  necessitate  a  separate  incision  in  the  middle  line.  When 
the  lip  is  extensively  involved,  the  cheek  is  completely  separated  from 
the  inferior  maxilla  to  the  middle  of  the  masseter  muscle.  After  the 
glands  are  cleaned  out  the  triangular  flaps  are  brought  together  and 
united  first  in  the  middle  line.  If  the  tension  is  great  or  considerable, 
from  the  amount  of  tissue  excised,  one  mattress  suture  should  be 
inserted  about  three-quarters  of  an  inch  from  the  central  line,  and  tied 
over  pads  of  gauze,  covered  with  oiled  muslin  to  prevent  soiling.     This 


INJURIES    AND    DISEASES    OF    THE    FACE    AND    JAW  151 

effectively  removes  undue  tension  from  the  sutures  in  the  center  of  the 
flaps.  The  stitches  uniting  cheek  posteriorly  are  now  inserted,  or  if 
previously  inserted  are  tied,  care  being  taken  to  include  the  entire 
thickness  of  cheek  or  upper  border.  For  this  purpose  interrupted 
silkworm-gut  or  a  running  stitch  of  chromicized  catgut  is  used.  A  small 
rubber  tube  should  be  inserted  in  the  posterior  angle  of  the  wound  on 
each  side,  to  drain  the  mouth  and  for  irrigation  purposes.  A  T-drain, 
size  of  a  lead  pencil,  should  also  be  inserted  through  the  submental 
space  to  the  mouth,  beneath  the  tip  of  the  tongue.  This  is  important. 
The  stationary  chin  tissue  is  of  the  greatest  importance  as  a  point 
of  fixation  for  the  flaps.  In  uniting  the  flaps  to  the  chin  in  the  centers 
it  is  well  to  omit  a  stitch  for  drainage  of  the  space  between  incisors  and 


Fig.  96. — (Grant.) 

flaps.  When  half  or  more  of  the  entire  lip  is  removed,  the  operation 
is  perfected  and  completed  by  making  an  incision  from  each  angle  of 
the  mouth  backward  and  slightly  downward  half  to  one  inch  in  length, 
down  to  the  buccal  mucous  membrane,  which  is  then  separated  from 
the  overlying  tissues  above,  below  and  posteriorly,  to  the  extent  of 
half  an  inch.  The  lip  above  and  below  is  now  beveled  from  the  inner 
border  in  order  to  conform  to  natural  conditions  and  also  to  make  it 
easier  to  cover.  The  mucous  membrane  is  now  divided  in  the  middle 
line  and  the  flaps  are  united  to  the  skin  by  one  continuous  suture  of 
chromicized  catgut." 

Rodent  Ulcer. — Rodent  ulcer,  a  chronic  form  of  carcinoma,  is  seen 
with  especial  frequency  on  the  upper  two-thirds  of  the  face — the  skin 


152  REGIONAL    SURGERY 

over  the  maxillary  antrum  and  inner  and  outer  canthi  being  the  chief 
seats  of  election.  It  usually  occurs  after  the  age  of  40,  begins  as  a 
painless  papule  or  wart,  which  in  the  course  of  8  or  12  months  may 
reach  the  size  of  a  split  pea.  This  knob  may  remain  stationary  for 
months  or  years,  but  sooner  or  later  begins  to  ulcerate  and  form  crusts 
— an  evidence  that  the  disease  is  becoming  more  active.  A  few  months 
following  the  beginning  of  crust  formation  the  ulcerative  process  begins 
to  extend  marginally  and  to  the  deeper  structures.  It  grows  increas- 
ingly, slowly  spreads,  destroying  everything  that  it  meets,  including 
bones,  and  producing  hideous  deformity.  This  destructive  process 
may  go  on  for  years,  the  general  health  remaining  fair.  At  times  the 
ulcerating  area  shows  a  limited  cicatrization  which,  in  the  course  of 
time,  again  breaks  down.  There  is  but  little  discharge  from  the 
ulcerating  surface.  The  ulcer  has  a  depressed  irregular  surface  with 
a  more  or  less  indurated  rolled-over  edge.  Neighboring  lymphatic 
glands  are  not  involved  and  no  metastasis  occurs.  Etiologically^ 
rodent  ulcer  is  a  form  of  cancer  having  its  origin  in  the  sebaceous  or 
sweat  glands.  Histologically,  it  is  made  up  of  columnar-shaped  cell 
nests  containing  rather  small  epithelial  cells. 

Treatment. — Early  operative  interference  is  necessary.  A  careful 
and  liberal  removal  of  a  good  margin  of  healthy  tissue  along  with  the 
lesion,  holds  out  encouragement  for  a  permanent  cure.  The  defect 
resulting  from  the  excision  is  to  be  made  good  by  skin  grafting  on  a 
granulating  surface  about  6  to  1 2  days  following  the  primary  operation. 
The  X-rays  have  a  remarkable  inhibitive  influence  on  this  growth 
and  in  a  considerable  number  of  cases  permanent  cures  result.  The 
X-ray  is  used  daily  for  10  minutes;  after  a  week's  application,  local 
inflammatory  reaction  follows.  The  treatment  is  kept  up  for  three  or 
four  weeks.  A  clearing  up  and  healing  very  frequently  follows  in 
several  weeks.  If  there  be  a  recurrence,  treatment  is  repeated.  Rad- 
ium has  proven  most  satisfactory,  and  conclusions  from  recent  reports 
indicate  that  it  may  become  the  treatment  of  choice. 

Sarcoma. — Primary  sarcoma  originating  from  the  soft  parts  of  the 
face  is  exceedingly  rare.  Most  sarcomata  of  the  face  have  their  starting 
point  from  the  deep  parts,  bones  or  parotid  glands.  Congenital  sarco- 
mata develop  from  the  soft  parts  of  the  face,  grow  rapidly  soon  after 
birth,  produce  early  metastasis,  and  terminate  life  generally  within  the 
first  18  months.  Histologically,  they  are  usually  angiosarcomata 
or  .  myxosarcomata.  Sarcomata  which  develop  later  in  life  present 
the  appearance  of  a  multiple  mass  of  papillomata.     The  predominating 


INJURIES    AND    DISEASES    OF   THE    FACE    AND   JAW  1 53 

type  is  the  melanotic  variety,  nodular  or  papillary  in  form,  and  show- 
ing dark  pigmentation.  The  tumor  is  slowly  progressive;  regional 
lymphatics  become  involved  and  later  systemic  metastasis  occurs. 
The  prognosis  of  sarcomata,  particularly  of  those  developing  soon 
.after  birth,  is  unfavorable. 

Treatment. — Early  radical  removal,  while  the  tumor  is  single  and 
localized,  should  be  done.  Diffuse  local  infiltration  and  lymphatic 
involvement  is  a  contraindication  to  operation. 

Angioma. — Angiomata  are  vascular  tumors.  If  the  constituent 
vessels  are  blood-vessels  the  lesion  is  designated  "ha^mangioma." 
Several  varieties  are  recognized — the  simple  and  hypertrophic  forms 
being  most  common.  Angioma  simplex,  also  known  as  birth  mark, 
appears  as  a  dark  red,  port  wine,  or  bluish  discoloration  of  the  skin  with- 
out elevation  of  surface.  Such  tumors  vary  in  size  from  a  small  speck 
to  an  involvement  of  a  greater  or  less  part  of  the  face,  are  limited  to 
the  skin  and  are  usually  observed  at  birth  or  appear  a  few  weeks  later. 
They  may  remain  stationary  or  grow  to  considerable  size.  The  skin 
involved  is  usually  smooth  and  bleeds  profusely  when  injured.  Pres- 
sure drives  the  blood  from  the  vessels,  the  color  immediately  return- 
ing when  pressure  is  removed.  These  tumors  are  benign  and  cause  no 
symptoms.  Patients  afiSicted  with  them  often  shun  publicity  and 
society  on  account  of  the  conspicuous  discoloration. 

Treatment. — External  applications  or  compressions  are  useless. 
Galvano-puncture  is  a  simple  valuable  treatment  for  small  naevi.  The 
technique  of  its  appHcation  is  fully  given  in  works  on  medical  electricity. 
The  injection  of  i  to  2  cc.  of  boiling  water,  forced  through  a  large- 
sized  h>'podermic  needle  and  injected  at  several  places,  produces  ab- 
sorption of  blood  pigment  and  formation  of  fibrous  tissue.  Injections 
should  be  repeated  each  three  to  four  weeks  until  all  parts  of  the  tumor 
have  been  reached.  The  subsequent  cosmetic  results  are  usually 
satisfactory.  The  best  results  are  obtained  by  a  radical  excision  of  the 
discolored  mass  followed  immediately  by  a  plastic  operation.  A  suitable 
flap  with  attached  pedicle  is  obtained  from  the  arm  as  in  the  Italian 
rhinoplasty.  Excision  followed  by  immediate  or  later  skin  grafting  is 
also  practised. 

The  hypertrophic  forms  of  haemangioma  appear  as  distinct  local 
swellings,  lobulated  tumor-like  growths  of  soft  elastic  consistency, 
with  a  bluish  or  red  overlying  skin.  The  majority  of  this  class  of  tumors 
exist  at  birth  or  develop  within  the  first  few  weeks.  Growth  is  rapid 
for  a  time  but  the  tumor  finally  becomes  stationary.     The  upper  lip  is 


154  REGIONAL   SURGERY 

the  chief  location  of  these  tumors.  Secondary  changes,  as  hemorrhage, 
ulceration,  and  inflammation  are  frequent.  Histologically,  these 
tumors  are  made  up  chiefly  of  convoluted  blood-vessels  with  a  relatively 
small  amount  of  interlobular  tissue. 

Treatment. — Treatment  consists  of  radical  excision  performed 
within  a  few  weeks  after  birth,  especially  when  the  swelling  is  of  a 
progressive  character ;  this  treatment  is  advisable  only  when  the  tumor 
is  very  small.  At  times  the  tumors  grow  very  rapidly  and  a  late  re- 
moval would  sacrifice  considerable  tissue  and  result  in  permanent 
disfiguration.  In  these  circumstances  the  best  treatment  is  the  in- 
jection of  hot  water,  as  in  simple  angiomata,  or  injection  of  absolute 
alcohol  as  recommended  for  similar  tumors  of  the  eyelids. 

Lymphangioma. — Tumors  in  which  lymphatic  channels  predomi- 
nate are  occasionally  seen  about  the  upper  or  lower  lips  at  birth,  or  they 
may  develop  afterward.  As  a  rule,  they  appear  in  the  form  of  a  diffuse 
swelling  leading  to  a  hypertrophy  of  the  involved  lips,  a  condition  com- 
monly known  as  "macrocheilia."  The  consistency  of  the  tumors  is 
variable,  depending  upon  the  amount  of  fibrous  tissue.  They  grow 
slowly  and  as  a  rule  progressively.  The  overlying  skin  is  usually  ad- 
herent to  the  deep  parts. 

Lymphangiomata  may  develop  from  any  part  of  the  face,  and  oc- 
casionally lead  to  considerable  deformity.  The  tumor  is  readily 
differentiated  from  hsemangioma  in  that  the  overlying  skin  shows  no 
discoloration.  A  great  many  angiomas  are  congenital  and  apparently 
they  develop  in  the  line  of  embryonic  fissures;  they  have  been  called 
by  Virchow,  "fissure  angiomas."  The  congenital  origin  of  lymphan- 
giomata is  more  frequent  than  that  of  the  haemangiomata.  They  have 
been  observed  on  the  eyelids,  the  cheeks,  and  the  lips,  particularly  the 
upper  lip. 

Treatment. — Well-defined  tumors  can  readily  be  excised.  The 
diffuse  and  infiltrating  variety  offers  considerable  difficulty  in  so  far 
as  a  complete  removal  is  concerned,  with  subsequent  cosmetic  re- 
sults. Partial  excision  usually  leads  to  progression  of  the  growth 
unless  followed  by  chemical  or  thermic  cauterization  of  the  marginal 
remnants. 

Lipoma. — Tumors  of  the  face  in  which  fatty  tissue  predominates, 
are  very  infrequent.  They  are  usually  well  defined,  encapsulated, 
single  or  lobulated,  the  overlying  skin  being  freely  movable.  The 
mixed  forms,  such  as  the  fibrplipomata  and  angiolipomata,  as  a  rule, 
are  not  encapsulated  but  have  a  diffuse  position  in  the  tissues.     The 


INJURIES    AND    DISEASES    OF    THE    FACE    AND   JAW  155 

growth  of  these  tumors  is  very  indefinite.  They  often  enlarge  slowly 
and  finally  become  stationary. 

Treatment. — On  account  of  the  disfigurement  caused  by  their  pres- 
ence, removal  is  usually  sought. 

Dermoids. — Dermoids  are  exceedingly  rare  about  the  face.  The 
margin  of  the  orbit,  inner  canthus,  and  root  of  the  nose  are  the  seats  of 
election.  The  majority  of  these  tumors  are  noticed  during  early 
childhood  in  the  form  of  slow-growing,  semi-fluctuating  nodes.  The 
overlying  skin  is  not  adherent  unless  the  cyst  becomes  infected.  Der- 
moids contain  a  caseous  fatty  material  and  hair.  An  opening  into  a 
dermoid  cyst  results  in  a  dermoid  fistula  which  discharges  sebaceous 
material;  projecting  hairs  are  often  visible. 

Treatment. — Realizing  that  the  contents  of  dermoids  is  the  result  of 
encased  epithelial  cell  activity,  the  cyst  having  skin  for  its  inner  lining, 
successful  treatment  must  accomplish  the  complete  removal  of  the 
cyst  wall. 

Sebaceous  cysts  are  usually  situated  near  the  scalp. 

Treatment  consists  in  removing  the  wall  by  dissection. 

Cutaneous  horns  are  local  wart-like  projections  having  for  their 
base  hypertrophied  papilla  which  are  covered  by  a  thick  layer  of 
cornified  epithelium.  The  base  must  be  removed  with  the  horn,  or  the 
latter  will  recur. 

Actinomycosis  {Lumpy  Jaw). — Etiology. — This  affection  is  caused 
by  the  fungus  known  as  actinomyces  bovis,  and  is  a  disease  most  common 
among  cattle.  The  source  of  human  infection  is  not  definitely  known 
but  is  supposed  to  be  introduced  through  infected  vegetables,  as 
in  chewing  certain  cereals  the  buccal  tissues  may  be  punctured  by 
a  barley  or  wheat  spikelet.  In  many  cases  carious  teeth  seem  to  be  the 
seat  of  primary  infection  and  the  case  is  mistaken  for  an  ordinary 
dental  affection.  The  lower  jaw  is  most  frequently  involved.  The 
disease  is  chronic,  resembling  sarcoma  in  its  clinical  features  and  in  its 
anatomical  location,  and  it  is  not  infrequently  diagnosed  as  such;  it 
usually  begins  in  the  gums  as  a  local  indurated  swelling  w^hich  slowly 
extends  to  the  neighboring  soft  parts  and  bones.  An  alveolar  abscess 
may  coexist.  The  induration  and  swelling  is  slowly  progressive,  the 
tumefaction  presenting  an  uniform  or  nodular  enlargement  of  board- 
like  hardness,  not  tender  to  pressure.  The  disease  runs  a  painless 
chronic  course  with  no  tendency  to  spontaneous  recovery,  and  in  the 
course  of  years  the  enlargement  may  be  so  great  as  to  cause  much 
disfigurement  of  the  face.     Lymphatic  glands  show  a  late  involvement. 


156  REGIONAL    SURGERY 

Untreated,  the  disease  usually  extends  and  in  time  proves  fatal. 
Leukocytosis  and  elevation  of  temperature  are  absent  unless  acute 
secondary  pyogenic  infection  is  present.  During  the  progress  of  the 
affection  small  actinomycotic  abscesses  form;  these  periodically  open 
on  the  skin  or  buccal  surface  and  discharge  a  purulent  material  con- 
taining yellow  granules  about  }io  inch  in  diameter.  The  granules, 
when  pressed  between  a  slide  and  coverslip  and  examined  micro- 
scopically show  a  central  hyaline  area  with  radial  striations.  His- 
tologically, actinomycosis  is  a  chronic  productive  inflammation. 

Treatment  consists  in  excising  and  curetting  the  diseased  tissue,  in 
adequate  drainage  and  in  the  internal  administration  of  potassium 
iodide,  in  doses  of  5  to  10  grains,  three  times  daily;  the  dose  is 
gradually  increased  until  60  to  120  grains  are  taken  daily.  After  two 
months,  copper  sulphate  is  substituted  in  doses  just  short  of  the 
nauseating  point,  and  after  five  to  eight  months  potassium  iodide  is 
again  given. 

Tuberculosis. — Tuberculosis  of  the  maxillary  bones  is  rare.  It  may 
be  primary  or  secondary.  The  primary  form  usually  occurs  in  the 
lower  jaw  and  manifests  itself  as  a  chronic  indurated  swelling,  slightly 
tender  to  pressure  and  practically  painless.  The  tuberculous  process 
may  form  fistulous  openings  through  the  overlying  skin,  discharging 
caseous,  purulent  material.  Regional  lymphatic  glands  are  enlarged. 
It  is  differentiated  from  a  sarcoma  in  that  the  latter  is  more  rapid  in 
progress  and  does  not  involve  the  lymphatic  glands.  Sometimes, 
however,  exploratory  excision  is  necessary  for  diagnosis. 

Treatment. — Treatment  is  along  the  same  general  lines  as  in  tuber- 
culous osteomyelitis  elsewhere.  Especial  care  should  be  taken  to 
avoid  the  formation  of  any  communication  between  the  tuberculous 
areas  and  the  buccal  cavity  as  secondary  infection  is  particularly  to  be 
avoided.  Secondary  tuberculous  ajffections  of  the  jaws  appear  in  the 
form  of  alveolar  abscesses  in  patients  suffering  from  pulmonary  tuber- 
culosis. Mixed  infection  is  always  present.  The  teeth  involved  should 
be  extracted,  the  cavity  curetted  and  the  mouth  kept  clean  with 
antiseptic  washes. 

Osteomyelitis. — Osteomyelitis  of  the  jaws  may  be  primary,  originat- 
ing from  the  circulation  or  secondary  by  extension  of  infection  from 
without,  as  in  compound  fractures,  or  by  extension  from  the  soft  parts. 
That  the  maxillary  bone  offers  a  natural  resistance  to  infection  is  evi- 
denced by  the  fact  that  with  the  innumerable  extractions  of  teeth  an 
atrium  of  infection  is  produced,  and  yet  infection  of  the  bone  does  not 


INJURIES    AND    DISEASES    OF    THE    FACE    AND    JAW  157 

occur.  However,  an  alveolar  abscess  (submucous,  or  a  gumboil,  D 
Fig.  97,  or  a  monoarthritis  at  the  apex  of  the  tooth,  A),  if  untreated 
may  lead  to  diffuse  osteomyelitis.  The  foci,  (B  and  B'),  originate  from 
A;  from  these  in  turn  develop  subperiosteal  abscesses  (C  and  C). 
If  the  focus  of  osteomyelitis  is  above  the  level  of  the  gingival  mucous 
membrane  (B),  then  a  mucous  fistula  (N)  forms;  on  the  other  hand, 
if  the  focus  is  below  the  gingival  mucous  level — as  often  occurs  on  the 
outer  side  of  the  jaw — a  cutaneous  fistula  (M)  will  form.  Infection  is 
most  common  in  the  lower  jaw,  is  usually  of  the  acute  type  and  may 


Fig.  97. — D.  Gumboil;  .1,  monoarUirilis  at  apex  tooth;  B,B',  foci  osteomyelitis;  C,C', 
subperiosteal  abscess;  .Y,  mucous  fistula;  M,  cutaneous  fistula. 

lead  to  extensive  necrosis.  Clinically,  it  is  characterized  by  pain, 
swelling,  extreme  tenderness,  and  symptoms  of  intoxication. 

Treatment  consists  in  exposing  the  diseased  areas,  removing  seques- 
tra and  establishing  adequate  drainage. 

Periostitis. — Periostitis,  an  inflammation  limited  to  the  periosteum, 
is  rare.  Osteoperiosiitis  is  a  more  fitting  term,  denoting  an  inflamma- 
tion of  the  periosteum  and  the  subperiosteal  bony  tissue.  It  is  usually 
secondary  to  dental  caries,  acute  in  onset,  with  pain,  tenderness,  and 
swelling  as  the  main  features. 

Treatment  should  be  directed  toward  draining  the  primary  focus. 
Hot  fomentations  are  useful  and  gratifying  to  the  patient.  If  swelling 
is  very  marked,  with  evidence  of  pus  formation,  incisions  are  indicated. 


158  REGIONAL    SURGERY 

Pyorrhcea  Alveolaris  {Riggs'  Disease) . — Pyorrhoea  alveolaris  consists 
of  a  chronic  inflammatory  condition  of  the  margin  of  the  gums  in  their 
relation  with  the  alveolar  periosteum  and  the  necks  of  the  teeth.  It 
is  a  septic  infection  thought  by  some  to  be  the  result  of  auto-intoxica- 
tion due  to  intestinal  stasis.  It  is  characterized  by  an  accumulation 
of  tartar  between  the  edges  of  the  gums  and  the  teeth,  whence  a  muco- 
purulent discharge  escapes.  Atrophy  of  the  alveolar  border  and  gums 
takes  place,  with  consequent  loosening  of  the  teeth,  which  may  fall  out. 
Only  a  few  teeth  may  be  involved  but  usually  the  disease  spreads  until 
nearly  all,  if  not  all,  are  attacked.  It  is  very  seldom  seen  in  people 
below  middle  life. 

Treatment. — The  tartar  should  be  removed  and  the  spaces  between 
the  necks  of  the  teeth  and  the  gums  mopped  out  with  strong  solutions 
of  nitrate  of  silver,  tincture  of  iodine,  or  some  other  reliable  antiseptic. 
Solutions  of  chlorate  of  potash  and  thymol  as  mouth  washes,  together 
with  the  most  scrupulous  use  of  dentifrices  and  the  sterilized  tooth 
brush,  afford  the  best  means  of  local  treatment.  Thoroughly  cooked 
foodstuffs  and  careful  elimination  preferably  with  an  occasional  dose  of 
blue  mass,  and  the  daily  administration  of  liquid  paraffine,  are  advised. 
Autogenous  vaccines  or  mLxed  stock  vaccines  may  be  used  with  ad- 
vantage. Formerly  when  this  disease  was  regarded  as  a  purely  local 
affection  the  prognosis  was  bad  as  to  cure;  to-day  it  is  more  hopeful. 

Note. — The  claim  that  endamoeba  buccalis  is  an  etiological  factor  in  Riggs'  Disease 
does  not  appear  to  be  substantially  established.  Endamoebas  are  to  be  found  in  pyorrhoea] 
pockets.  Although  numerous  observers  state  definitely  that  the  endamoebas  are  the 
cause  of  periodental  diseases,  and  that  these  are  curable  by  the  hj-podermic  and  local  use 
of  emetin  hydrochlorid,  very  many  dental  surgeons  are  not  in  accord  with  this  opinion. 

Syphilis  of  the  Jaws. — Syphilitic  disease  of  the  jaws  is  exclusively 
a  tertiary  affection,  the  lower  jaw  being  most  commonly  involved.  The 
disease  manifests  itself  by  a  thickening  of  the  periosteum,  the  formation 
of  gummata  and  caries.  Diffuse  or  circumscribed  painless  sweUings 
develop  on  the  external  surface  of  the  lower  jaw.  Exostoses  frequently 
form,  and  periosteal  gummata  lead  to  necrosis  and  absorption  of  bone; 
thus  bony  structures  disappear  and  fragility  results.  This  process  is 
many  times  associated  with  a  pyogenic  infection.  The  diagnosis  is  made 
from  the  history  of  the  case  and  the  detection  of  painless  periosteal 
thickening.  When  suspected,  the  diagnosis  should  be  clinched  by  a 
positive  Wassermann  reaction. 

Treatment. — Treatment  resolves  itself  into  the  application  of  general 
syphihtic  remedies.  If  secondary  infection  or  sequestra  exist,  surgical 
measures  are  indicated. 


INJURIES    AND    DISEASES   OF    THE    FACE    AND    JAW  1 59 

Phosphorus  necrosis  of  the  lower  jaw  is  at  present  a  rare  disease. 
The  use  of  red  phosphorus  and  the  exclusion  of  phosphorus  fumes  in 
match  factories,  has  practically  eradicated  this  affection. 

Tumors  of  the  Jaws — General  Characteristics. — Sarcoma  is  the 
most  common  tumor  of  the  jaws,  the  upper  and  lower  jaw  being  about 
equally  affected.  It  occurs  most  frequently  during  young  and  middle 
life.  Traumatism,  chronic  alveolar  ulceration,  or  abscess  are  predis- 
posing factors.  Sarcomata  are  usually  vigorously  malignant.  A  tumor 
may  be  sarcomatous  from  the  very  beginning,  or  may  later  become  sar- 
comatous. The  anatomic  origin  of  sarcoma  of  the  upper  jaw  is  usually 
from  the  alveolar  process  and  the  body.  Occasionally  these  tumors 
may  have  origin  in  the  hard  palate,  maxillary  antrum,  sphenomaxillary 
fossa  or  nasopharynx.  Sarcomata  of  the  lower  jaw  originate  with  equal 
frequency  from  the  body  or  alveolar  process.  A  sarcoma  may  originate 
from  the  surface  or  central  parts  of  the  maxillary  bones.  The  surface 
or  periosteal  sarcomata  have  their  origin  in  the  periosteal  tissues. 
Structurally  the  periosteal  sarcomata  may  be  divided  into  several  his- 
tomorphological  types;  the  mixed-cell  variety,  containing  a  relatively 
large  amount  of  intercellular  material,  is  the  least  malignant  and  may 
exist  as  a  benign  tumor.  However,  it  must  be  noted  that  apparently 
benign  tumors  may  at  any  time  become  malignant.  The  round  or 
spindle-celled  varieties  are  usually  progressively  malignant,  but  most 
malignant  of  all  is  the  melanotic  (pigmented)  sarcoma.  The  central 
or  myelogenous  sarcomata  originate  from  the  bone  marrow.  Histo- 
logically they  are  made  up  of  multinucleated  cells  imbedded  in  a  con- 
siderable quantity  of  round  or  spindle-shaped  cells,  the  intercellular 
substance  being  usually  of  a  homogeneous  nature.  Blood-vessels 
are  quite  abundant  and  hemorrhage  frequently  takes  place  within 
the  tumor  substance,  resulting  in  the  formation  of  blood  cysts  which 
later  become  altered  in  color  and  consistency.  Their  growth  is  fairly 
rapid  and  they  may  attain  considerable  size,  invading,  destroying, 
and  pushing  neighboring  tissues  aside.  The  tumor  is  soft,  does  not 
produce  metastases,  and  is  to  be  regarded  as  only  locally  maUgnant. 
The  history  of  trauma  and  chronic  inflammation  of  the  jaw  as  predis- 
posing factors,  is  of  prime  importance  in  making  a  diagnosis. 

Periosteal  sarcoma  of  the  lower  jaw  begins  in  the  form  of  a  small, 
hard,  painless  elevation  which  generally  originates  from  the  outer  or 
inner  surface  of  the  jaw  and  is  slowly  progressive  in  growth.  At  times 
it  may  become  stationary,  and  later  increases  rapidly.  The  growth  is 
often  painful  and  tender,  and  as  it  increases  in  size  there  is  dilhculty  in 


l6o  REGIONAL   SURGERY 

the  use  of  the  jaw;  the  teeth  become  loose,  and  the  mucous  membrane 
overlying  the  tumor  may  ulcerate.  Metastasis,  as  a  rule,  does  not 
occur.  Regional  lymphatics  become  enlarged  if  there  be  infection  of 
the  oral  or  tumor  tissues.  In  doubtful  cases  removal  of  a  part  of  the 
tumor  for  microscopic  examination  may  be  necessary  for  a  correct  diag- 
nosis. The  diagnosis  of  the  central  or  myelogenous  sarcoma  may  be 
difficult  in  the  very  beginning  for  the  reason  that  these  tumors  originate 
in  the  deep  parts  of  the  bone  and  therefore  their  character  is  frequently 
not  made  out  until  they  break  through  the  surface. 

A  tumor  growing  into  the  maxillary  sinus  may  reach  a  considerable 
size  without  symptoms;  therefore  X-ray  sinus  examination  is  important 
if  patients  complain  of  a  dull  pain  and  pressure  sensation  about  the 
maxillary  sinus  region;  this  symptom  may  be  due  to  pressure  of  a 
tumor  from  within,  outward.  Finally  the  tumor  breaks  through  the 
outer  shell  of  the  involved  bone,  and  becomes  manifest.  Distant 
metastasis,  as  a  rule,  does  not  take  place,  and  regional  lymphatic  glands 
are  seldom  the  seat  of  secondary  deposits.  Enlarged  glands  may  result 
from  local  infection. 

Treatment. — The  degree  of  operative  removal  depends  upon  the 
histologic  make-up  of  the  tumor.  A  giant-celled  sarcoma  is  least 
malignant  and  often  a  partial  removal  will  result  in  a  cure,  whereas  a 
round  or  a  spindle-celled  sarcoma  requires  early  and  complete  removal. 
A  thorough  curettage  when  the  tumor  is  seated  in  the  medullary  spaces 
of  the  inferior  maxillary  bone  will  usually  result  in  permanent  cure  and 
the  disfiguring  results  of  a  radical  excision  will  be  avoided.  In  every 
case  which  is  not  manifestly  inoperable,  an  attempt  should  be  made  to 
remove  all  of  the  tumor  by  excision  or  curettage.  If  the  tumor  is  of 
periosteal  origin,  is  rapid  in  growth,  whether  with  or  without  glandular 
enlargement,  an  extensive  and  radical  excision,  including  a  fair  margin 
of  adjoining  healthy  tissue,  and  the  removal  of  enlarged  lymphatic 
glands,  holds  out  the  only  chance  of  permanent  cure. 

Prognosis,  as  a  rule,  is  favorable  if  the  tumor  is  removed  early  and 
completely;  it  depends  also  on  the  extent  of  the  involvement  and  the 
histologic  character  of  the  tumor.  An  unfavorable  prognosis  is  made  in 
cases  where  the  growth  has  become  very  extensive,  involving  neigh- 
boring tissues,  and  showing  metastasis  in  local  lymph  glands. 

Epulis. — The  term  epulis  is  an  ancient  one  and  only  of  topographical 
significance.  An  epulis  is  a  tumor  attached  to  the  alveolar  process  of 
either  the  upper  or  lower  jaw,  most  commonly  the  latter.  It  is  a  tumor 
of  young  adult  life  originating  either  from  the  periosteum  of  the  alveolar 


INJURIES    AND    DISEASES    OF    THE    FACE    AND    JAW 


l6l 


process,  the  connective  tissue  between  the  periosteum  and  the  alveolar 
mucous  membrane,  the  edge  of  the  tooth  or  its  socket.  Gaps  between 
the  teeth  in  the  bicuspid  and  first  molar  region  are  the  places  of  election. 
Two  varieties  are  recognized,  the  simple  and  the  malignant.  Histo- 
logically, a  simple  or  benign  epulis  is  made  up  of  spindle-shaped  cells 
which  in  some  tumors  may  be  closely  packed,  so  as  to  give  the  growth 
all  of  the  characteristics  of  a  true  sarcoma.     Again,  the  tumor  may  be 


Fig.  98. — Multiple   libroma;   simple  epulis — probably  a   unique  case.     (Patient  of  Dr. 

W.  L.  Shearer.) 


made  up  of  a  relatively  large  amount  of  intercellular  connective  tissue, 
thus  simulating  a  fibroma.  Clinically,  a  simple  epulis  is  a  benign 
tumor,  slow  in  growth,  requiring  one  to  three  years  to  reach  the  size 
of  a  cherry  or  walnut.  It  usually  appears  first  between ^two^teeth  in 
the  form  of  a  small  nodule,  and  spreads  about  the  teeth  and  alveolar 
border  (Fig.  98) .  The  red  fleshy  mass  is  usually  smooth,  at  times  lobu- 
lated,  elastic  in  consistency,  and  covered  by  normal  mucous  membrane. 


l62  REGIONAL    SURGERY 

If  the  tumor  originates  from  the  socket  of  a  tooth  it  may  be  peduncu- 
lated. A  simple  epuHs  may  grow  to  considerable  size  and  interfere 
with  mastication  and  speech.  Malignant  epulis  is  a  giant-celled  sar- 
coma originating  either  from  the  alveolar  periosteum  or  medullary  tis- 
sues of  the  bone.  Histologically,  the  tumor  is  largely  made  up  of 
multinucleated  spindle  and  round  cells,  blood-vessels  being  more  abun- 
dant than  in  the  simple  variety.  The  growth  projects  from  the  gum 
border  as  a  soft,  dark  red  mass  covered  with  mucous  membrane  which 
is  very  apt  to  ulcerate.  This  tumor  is  only  locally  malignant  and  may 
cause  considerable  destruction  of  the  tissues.  Lymphatic  glands  are 
not  involved  but  may  become  enlarged  by  infection  from  the  ulcerated 
surfaces. 

Diagnosis  of  epulis  is  not  difficult.  The  growth  takes  the  form  of  a 
circumscribed,  painless  swelling,  of  slow  enlargement.  An  epulis 
originating  at  the  root  of  a  tooth  will  push  the  tooth  outward,  finally 
dislodging  it.  The  process  is  accompanied  by  a  dull  ache  or  pressure 
pain. 

Treatment.— TTea,tm.ent  consists  of  radical  removal.  Curettage  or 
partial  excisions  often  lead  to  recurrence.  In  all  cases  a  fair  margin 
of  adjoining  healthy  bone  should  be  removed  with  the  growth.  A 
giant-cell  epulis  frequently  invades  the  body  of  the  jaw,  and  in  such 
cases  excision,  followed  by  curettage  and  cautery,  is  indicated. 

Carcinoma. — Carcinoma  of  the  jaw  is  a  tumor  of  the  aged,  and  is 
more  common  in  the  upper  than  in  the  lower  jaw.  It  may  be  primary 
or  secondary.  Primary  carcinomata  can  develop  from  the  epithelial 
cells  fining  the  mucous  membrane  which  overlies  certain  parts  of  the 
maxillary  bones.  The  epithefial  lining  of  the  maxillary  sinus,  and  of 
mucous  glands,  as  well  as  certain  paradental  indentations,  may  also 
be  the  seat  of  the  primary  tumor.  Secondary  carcinomata  are  due  to 
an  extension  of  a  primary  tumor  which  has  originated  from  the  parotid 
glands,  or  from  the  tongue  or  lips.  Metastatic  carcinoma  may  also 
occur.  Chronic  ulceration  about  the  mouth  and  teeth,  and  a  syphilitic 
soil,  are  predisposing  factors. 

Symptoms. — Pain,  the  first  and  most  constant  sign,  may  be  local- 
ized, but  usually  there  is  a  dull  ache  of  one-half  of  the  face,  radiating 
backward,  and  as  the  tumor  enlarges  pressure  symptoms  develop. 
In  case  the  upper  jaw  is  the  seat,  the  nostril  of  the  affected  side  becomes 
blocked.  There  is  swelling  of  the  face.  The  tumor  may  invade  the 
maxillary  antrum  and  as  it  develops  it  destroys  structures  in  its  path; 
extensive  ulcerations  coexist.     Mastication   and   speech  become  im- 


INJURIES    AND   DISEASES    OF    THE    FACE    AND    JAW  1 63 

paired,  the  breath  is  fetid  and  there  is  excessive  salivary  secretion.  The 
ulcerating  surfaces  bleed  readily.  The  submaxillary  and  cervical 
glands,  as  a  rule,  show  early  enlargement.  Carcinoma  of  the  jaw  is 
one  of  the  most  rapid  and  malignant  affections.  The  rapidity  of  the 
growth,  the  pain,  lymphatic  enlargement,  early  ulceration,  and  age  of 
the  patient,  will  readily  differentiate  it  from  a  sarcoma. 

Treatment. — The  prognosis  is  very  unfavorable  even  with  early 
and  radical  operation.  If  the  tumor  has  infiltrated  locally  and  if  there 
is  lymphatic  enlargement,  any  operative  measures  are  useless.  It  is 
only  in  the  early  stage,  while  the  tumor  is  yet  localized,  that  a  radical 
excision  is  indicated.  The  earher  the  removal,  the  better  the  prospects 
of  a  permanent  cure.  Inoperable  cases  can  be  stayed  to  some  extent 
by  radium  or  X-ray. 

Fibroma.^ — A  fibroma  is  a  dense  tumor  occurring  more  frequently 
in  the  upper  than  the  lower  jaw.  It  is  painless,  slow-growing  and  most 
common  in  the  young.  The  tumor  may  develop  from  the  periosteum 
or  central  parts  of  the  bone,  and,  although  their  growth  is  exceedingly 
slow,  these  tumors  may  reach  considerable  size.  Tumors  which  develop 
within  the  bone  cannot  be  recognized  until  by  pressure  atrophy  they 
break  through  the  bone.  As  enlargement  takes  place,  the  tumor  may 
project  into  the  oral  or  accessory  cavities.  Growth,  as  a  rule,  is  very 
slow,  and  at  times  is  associated  with  pressure  symptoms. 

Treatment. — Operative  removal  is  always  indicated.  The  prognosis 
is  favorable,  but  the  possibility  of  transformation  of  benign  into  sarco^ 
matons  tumors,  must  be  kept  in  mind. 

Adamantoma.^During  the  development  of  a  tooth  the  enamel  cells" 
surround  the  entire  embryonic  tooth,  but  as  the  tooth  develops  the 
enamel  cells  gradually  disappear  around  that  part  known  as  the  root, 
and  persist  only  as  a  dense  covering  of  the  crown  of  the  tooth.  If, 
during  the  embryonic  stage,  certain  masses  of  these  enamel  cells  remain 
deeply  placed  (so-called  cell  rests  or  paradental  epithelial  nests)  and 
subsequently  begin  to  proHferate,  a  new  growth  called  adamantoma 
results.  Paradental  cell  rests  may  be  some  distance  away  from  the 
root  of  a  tooth,  and  thus  the  tumors  be  independent  of  the  tooth. 
Histologically,  adamantoma  belongs  to  the  cancer  group.  It  is  the 
least  malignant  form  of  epithehal  tumor.  The  tumor  is  most  frequently 
met  with  in  young  adults,  the  molar  portion  of  the  lower  jaw  being  the 
most  common  location.  The  first  evidence  of  its  presence  is  a  projec- 
tion from  the  alveolar  process.  Occasionally  the  tumor  develops  a  few 
weeks  after  the  extraction  of  a  tooth.     Its  growth  is  slow,  but  com- 


164  REGIONAL    SURGERY 

monly  progressive,  and  it  may  reach  the  size  of  an  orange  or  larger. 
Xo  metastasis  occurs;  pain,  if  present,  is  due  to  pressure  or  infection. 
The  tumor  is  of  irregular  outHne,  and  on  section  is  cystic.  Micro- 
scopically, mucous,  fibrous,  and  epithelial  tissues  make  up  the  bulk  of 
the  tumor. 

Treatment. — As  much  of  the  growth  should  be  removed  as  is  con- 
sistent with  the  usefulness  of  the  lower  jaw.  If  the  tumor  has  made 
considerable  headway  and  invaded  the  greater  part  of  the  bone,  re- 
section of  the  involved  jaw  along  with  the  tumor  is  indicated.  Partial 
removals  have  resulted  in  permanent  cures. 

Odontoma. — This  is  a  tumor  resembhng  the  structure  of  a  tooth, 
and  having  the  same  degree  of  hardness.  It  usually  projects  from  the 
outer  surface  of  the  alveolar  process.  The  mass  is  readily  shelled  out 
after  incising  the  overlying  mucous  membrane.  Crown  and  root 
odontomata  are  hard  tumors  projecting  either  from  the  neck  or  root 
of  the  tooth. 

Follicular  Dental  Cysts  {Follicular  Odontoma). — These  tumors  result 
when  there  occurs  a  disturbance  in  the  normal  development  of  a  tooth, 
erpecially  when  there  is  an  interference  with  the  eruption  or  third  stage 
of  dentition,  and  the  partially  developed  tooth,  covered  by  a  fibrous 
capsule,  remains  in  the  bone.  As  a  result  the  encapsulated  mass  en- 
larges and  finally  projects  from  the  alveolar  process.  The  contents 
may  be  mucous,  fatty,  and  clear  or  colored  fluid,  in  which  are  found 
rudiments  of  tooth  structure.  The  growth  of  the  tumor  is  slow.  It 
first  manifests  itself  as  a  well-defined  nodule  which  may  project  from 
the  alveolar  process,  or  if  deeply  seated,  lead  to  an  expansion  of  the 
bony  walls.  As  the  development  of  the  cyst  advances,  a  new  growth 
of  bone  takes  place  in  its  wall;  the  bulging  bony  wall  of  these  cystic 
enlargements  is  not  a  mere  expansion  of  the  original  wall  of  the  jaw 
bone.  The  cystic  growth  may  sometimes  reach  a  large  size  and  cause 
considerable  facial  deformity.  The  X-ray  should  make  the  diagnosis 
positive. 

Treatment. — Remove  wall  of  cyst  with  curved  scissors  or  scalpel 
and  bone-cutting  forceps. 

Prognosis  is  good  as  a  rule,  no  recurrence  taking  place  after  partial 
removal. 

Cystoma. — Cystomata  are  tumors  having  a  connective-tissue 
stroma,  in  which  are  embedded  cystic  cavities.  These  tumors  are  the 
result  of  epithelial  inclusions  within  the  substance  of  the  jaw.  During 
their  growth  the  surrounding  bone  undergoes  atrophy,  and  the  cystic 


INJURIES    AND    DISEASES    OF    THE    FACE    ANT)    JAW  1 65 

tumor  becomes  surrounded  by  a  fragile  wall  of  thin  bone,  through 
which  it  breaks,  and  extends  into  the  soft  parts.  As  a  rule,  the  nature 
of  the  tumor  is  first  recognized  at  operation,  which  consists  in  excising 
and  removing  all  cyst  cavities. 

Osteoma,  chondroma,  and  mixed  tumors  rarely  develop  from  the 
jaw. 

Trifacial  Neuralgia. — Etiology. — The  essential  cause  of  trifacial 
neuralgia  is  unknown.  Sometimes  there  is  a  distinct  hereditary  his- 
tory. It  seems  that  the  majority  of  cases  are  due  to  some  form  of 
systemic  or  chemical  intoxication  or  infection.  The  chemical  toxins 
are  chiefly  the  mineral  poisons,  lead,  arsenic,  mercury,  alcohol,  and 
nicotine.  Auto-intoxications  due  to  chronic  intestinal  stasis  or  chronic 
constipation  are  also  blamed.  Many  of  the  most  severe  types  of  tri- 
facial neuralgia  occur  in  individuals  who  present  all  the  symptoms  com- 
mon to  chronic  intestinal  intoxication.  Among  the  infectious  causes, 
malaria  stands  first,  especially  the  chronic  variety  associated  with 
enlarged  spleen.  Other  infectious  diseases,  except  syphihs,  are  incom- 
parably less  often  the  cause  of  neuralgia.  In  syphilis  the  neuralgic 
affection  may  be  due  to  interstitial  changes  in  the  nerves,  or  to  pressure 
on  the  nerve  the  result  of  periostitis  or  gumma  formation.  Syphihtic 
neuralgia  is  a  late  manifestation,  and  neuralgia  in  the  early  stage  of 
syphilis  must  be  ascribed  to  other  causes.  Some  relation  between 
"colds"  and  the  cause  of  neuralgia  surely  exists.  Quite  frequently 
within  a  few  hours  after  facing  a  cold  wind,  the  individual  is  "struck" 
with  an  attack  of  supraorbital  neuralgia.  Sinus  infection  may  be  the 
direct  cause  of  neuralgia.  The  metaboHc  intoxication  of  pregnancy 
may  be  the  only  etiologic  factor  discoverable. 

Pathology. — No  definite  and  constant  pathologic  changes  are  found 
in  the  Gasserian  ganglion  even  in  severe  cases  of  trifacial  neuralgia. 
It  is  evident  that  trigeminal  neuralgia  is  not  a  definite  disease,  but 
merely  a  symptom  of  various  processes  affecting  the  fifth  nerve  any- 
where in  its  course.  Neuritis,  beginning  in  the  terminal  division  and 
tending  to  ascend,  is  the  most  common  form  of  the  disease.  When 
of  ganglionic  origin  the  trouble  begins  as  an  interstitial  inflammation 
in  the  Gasserian  ganglion,  and  is  most  severe  and  progressive.  A  cen- 
tral neuritis,  either  in  the  posterior  nerve  root  or  optic  thalamus,  evi- 
dently exists.  The  central  irritation  causes  the  peripheral  pain,  which 
ceases  on  section  of  the  posterior  root  of  the  Gasserian  ganglion. 

In  neuralgic  affections  of  the  ophthalmic  division,  the  pain  is  most 
severe  in  the  supraorbital  region,  and  extending  up  to  the  vertex  fre- 


1 66  REGIONAL   SURGERY 

quently  involves  the  adjacent  temporal  region  and  the  eyeball.  The 
conjunctiva  becomes  congested,  lachrymation  is  increased,  and  there 
is  extreme  sensitiveness  to  pressure  over  the  supraorbital  foramen. 
The  skin  of  the  involved  region  becomes  reddened,  swollen,  and  tender 
to  pressure. 

When  the  second  division  (supramaxillary  nerve)  is  affected,  the 
pain  is  especially  located  about  the  upper  jaw,  the  teeth,  gums,  and 
hard  palate.  The  skin  over  the  lateral  nasal  and  infraorbital  regions  be- 
comes sHghtly  swollen  and  tender.  Quite  often  the  patient  seeks  re- 
lief from  the  aching  teeth,  which  are  frequently  extracted  regardless  of 
their  healthy  condition.  The  patient  is  not  relieved  for  the  reason 
that  the  entire  jaw  is  the  seat  of  pain.  In  all  cases  of  toothache  with- 
out decay,  one  must  always  suspect  neuralgic  conditions.  In  neuralgia 
of  the  third  division  (inframaxillary  nerve),  the  pain  is  located  in  the 
tongue,  floor  of  the  mouth,  lower  jaw,  and  sometimes  the  skin  of  the 
lateral  maxillary  and  auriculo-temporal  region. 

Symptoms,  Diagnosis. — The  distribution  of  the  pain  depends  upon 
the  branches  of  the  trifacial  involved.  It  may  be  Hmited  to  certain 
terminals  of  one  of  the  three  divisions.  In  the  central  form  of  the 
disease,  the  pain  corresponds  to  the  distribution  of  all  three  trunks. 

Neuralgic  pains  are  commonly  confined  to  one  side  of  the  face  and 
forehead.  The  pain  is  usually  constant,  with  paroxysms  of  severe 
attacks,  or  there  may  be  pain-free  intervals  between  the  attacks,  and 
again  in  some  cases,  the  pain  is  continuous  without  exacerbations.  In 
the  paroxysmal  attacks  the  pain  is  stabbing,  tearing,  and  of  a  lightening- 
like,  sudden  onset.  The  pains  may  occur  at  intervals  of  a  few  minutes 
or  of  hours,  and  last  from  one  to  five  minutes. 

The  parts  are  usually  sensitive  to  touch,  and  are  at  times  reddened 
and  swollen.  During  the  attacks,  motion  of  the  parts  increases  the 
pain.  The  most  sensitive  point  to  pressure  is  at  the  exit  of  the  nerve 
from  its  bony  canal,  especially  is  this  true  of  the  supraorbital  and  infra- 
orbital nerves.  The  most  severe  type  of  trifacial  neuralgia  is  associated 
with  a  facial  spasm  and  bears  the  distinctive  name,  "tic  douloureux." 
The  spasm  of  the  facial  muscles  is  secondary  to  the  pain.  Before  de- 
ciding upon  the  diagnosis  of  facial  neuralgia  one  must  exclude  pains 
due  to  local  inflammations,  rheumatism,  and  pain  due  to  pathological 
changes  in  the  teeth  or  sockets.  Pain  in  these  conditions  is  constant 
and  diffuse,  and  not  Hmited  to  the  distribution  of  certain  nerves.  No 
differentiation  is  at  present  estabhshed  between  a  true  neuritis  and  a 
neuralgia  of  the  trifacial  nerve. 


INJURIES    AND    DISEASES    OF    THE    FACE    AND    JAW  167 

Treatment. — The  treatment  of  trifacial  neuralgia  should  first  be 
directed  to  the  cause.  It  is  a  known  fact  that  the  condition  is  fre- 
quently secondary  to  other  pathologic  processes  which,  if  relieved,  lead 
to  cure  of  the  neuralgia.  In  those  cases  in  which  an  etiologic  factor  can- 
not be  determined,  one  must  treat  the  neuralgia  as  a  primary  affection 
of  some  part  of  the  nerve  tract.  Every  case  demands  a  most  careful 
examination  as  to  the  possible  etiologic  factor.  Acute  and  subacute  mild 
cases  are  as  a  rule  benefited  by  non-surgical  treatment.  In  chronic  or 
severe  cases  the  outlook  from  palliative  treatment  is  not  so  encourag- 
ing. The  first  treatment  should  always  be  medicinal,  mechanical, 
physical,  or  electric.  The  most  useful  remedies  are  Fowler's  solution 
of  arsenic,  belladonna,  strychnine,  aconite,  and  large  doses  of  phosphate 
of  quinine.  AntisyphiHtic  treatment  is  employed  if  there  is  any  sus- 
picion of  syphilis  (even  if  a  Wassermann  reaction  is  negative).  Gal- 
vanism of  the  affected  nerve  tracts  should  supplement  internal  treat- 
ment. Local  applications  of  heat  or  some  irritating  liniment  will  often 
be  useful  adjuncts.  If  the  action  of  medicine  is  unavailing,  recourse  to 
injections  of  95  per  cent,  alcohol  directly  into  the  substance  of  the 
affected  nerve  is  indicated.  If  recurrence  takes  place,  the  alcohol  in- 
jection may  be  repeated  as  often  as  becomes  necessary.  Attempts 
should  always  be  made  to  inject  the  trunk  of  the  affected  nerve,  and 
if  this  is  not  possible,  the  branches  may  be  injected  separately.  An 
exact  anatomic  knowledge  of  the  region  to  be  injected,  is  a  prerequisite. 
The  amount  of  alcohol  injected  depends  on  the  size  of  the  nerve — from 
10  to  30  minims  of  the  commercial  grain  alcohol  suffices.  The  in- 
jecting needle  should  enter  the  nerve  fiber.  Injections  into  the  im- 
mediate vicinity,  so  that  the  alcohol  will  surround  the  nerve,  are  of 
some  benefit ;  though  not  so  effective  as  injections  into  the  nerve,  they 
may  serve  the  purpose  in  case  of  small  nerve  fibers.  Alcohol,  when  in- 
jected into  a  nerve,  causes  a  degeneration  of  the  distal  fibers.  Return 
of  sensation  or  of  the  original  trouble  is  frequently  observed  and  is 
due  to  regeneration  or  formation  of  new  axons  distal  to  the  point  of 
the  alcohol  injection. 

Operations  upon  the  peripheral  nerves  and  Gasserian  ganglion  can 
be  undertaken  if  alcohol  injections  have  not  been  successful.  The 
painful  peripheral  nerve,  after  careful  isolation,  can  be  torn  or  twisted 
from  its  bony  canal,  a  procedure  highly  praised  by  Belgian  surgeons. 
Following  the  avulsion  or  resection,  the  bony  canal  can  be  blocked  with 
lead  plugs  or  metal  screws,  as  advocated  by  Mayo.  Simple  section 
of  a  sensory  nerve  will  give  but  a  few  weeks'  relief,  as  sensory  nerves 


1 68  REGIONAL   SURGERY 

are  very  prone  to  regeneration.  The  greater  the  gap  between  the  cut 
ends,  the  longer  the  delay  in  regeneration.  The  above  procedure  is 
especially  indicated  in  affections  of  the  superior  maxillary  and  supra- 
orbital nerves.  If  injections  and  resections  fail,  intracranial  operations 
are  indicated,  especially  when  all  three  branches  of  the  trifacial  nerve 
are  involved.  Tearing  away,  or  resection  of  the  Gasserian  ganglion 
is  no  longer  practised.  Section  of  the  central  root  of  this  ganglion  seems 
to  be  the  operation  of  the  future.  The  rationale  of  the  operation  de- 
pends upon  the  inability  of  the  central  root  to  undergo  regeneration. 
This  is  explained  by  the  fact  that  the  trophic  cell  body  of  the  sensory 
fibers  is  situated  in  the  Gasserian  ganglion,  that  a  section  of  the  afferent 
axon  of  these  gangHonic  cells  leads  to  a  degeneration  of  the  sensory 
fibers,  going  brainward.  The  degeneration  of  the  posterior  root  fibers 
will  extend  to  the  nuclei  of  termination  in  the  brain.  The  posterior 
root  fibers  are  covered  by  a  neurilemma  which  disappears  as  the  fibers 
enter  the  spinal  cord  or  brain;  therefore  all  the  nerve  fibers  of  the  central 
nervous  system  are  incapable  of  regeneration.  Only  those  fibers  pro- 
vided with  a  neurilemma  have  the  possibility  of  regeneration. 
The  operations  for  trifacial  neuralgia  are  described  on  p.  173, 
Etiology  of  Facial  Paralysis. — The  long  and  complicated  course  of 
the  facial  nerve  through  its  bony  canal  in  the  temporal  bone,  and  the 
fact  that  the  rigid  walls  of  the  canal  are  in  close  contact  with  the  nerve, 
make  it  easy  for  this  nerve  to  be  compressed  by  bone  injuries  distort- 
ing the  canal,  as  in  basal  skull  fractures  involving  the  petrous  portion 
of  the  temporal  bone,  or  inflammatory  processes  within  or  external  to 
the  nerve.  The  chief  causes  leading  to  a  peripheral  paralysis  are  basal 
skull  fractures,  middle-ear  disease,  tumors  of  the  internal  ear,  menin- 
gitis, syphilis,  aneurisms,  rheumatic  conditions,  and  complicating  acute 
infectious  diseases.  Injuries  to  the  nerve  at  its  point  of  exit  from  the 
stylomastoid  foramen,  as  by  blows,  stab  wounds,  compression  by  en- 
larged glands,  or  tumors,  are  prominent  etiologic  factors.  The  most 
common  cause,  however,  of  peripheral  paralysis  is  a  neuritis  due  to 
exposure  to  a  cold  draught  on  the  face,  especially  during  sleep.  As 
a  result  the  nerve  swells  in  its  unyielding  bony  canal,  and  paralysis 
follows;  this  form  of  paralysis  is  called  Bell's  palsy.  Central  facial 
paralysis  may  be  due  to  a  lesion  in  the  pons,  crus,  internal  capsule  or 
cerebral  cortex.  Hemorrhage,  embolism,  abscess  and  syphilitic  proc- 
esses are  the  usual  causes. 

Symptoms  and  the  Determination  of  the  Seat  of  the  Facial  Lesions. — 
Facial  paralysis  may  be  of  gradual  or  sudden  onset,  depending  on  the 


INJURIES    AND    DISEASES    OF   THE    FACE    AND    JAW  1 69 

exciting  cause.  With  sudden  and  severe  compression  or  section  of  the 
nerve,  the  symptoms  are  immediate,  and  in  gradual  compression  or 
ascending  neuritis,  the  paralysis  slowly  develops.  The  patient  first 
notices  that  he  is  unable  to  control  labial  positions,  puff  out  his  cheeks, 
or  whistle.  The  face  and  nose  draw  toward  the  unaffected  side.  The 
eye  on  the  diseased  side  cannot  be  completely  closed  nor  the  eyebrow 
elevated.  The  paralyzed  side  cannot  be  wrinkled.  When  the  mouth 
is  widely  opened  the  labial  cleft  is  smaller  on  the  paralyzed  side;  the 
tongue  frequently  deviates  toward  the  sound  side.  The  buccinator 
being  paralyzed,  food  and  saliva  accumulate  about  the  internal  buccal 
region.  In  lesions  of  the  facial  nerve,  at  or  above  the  geniculate  gang- 
Hon,  the  sense  of  taste  is  impaired  and  high-pitched  notes  are  not  readily 
recognized  by  the  affected  ear.  Given  a  case  of  facial  paralysis,  the 
first  question  to  decide  is  whether  we  have  a  central  or  peripheral  lesion. 
In  central  lesions,  usually  caused  by  hemorrhage,  the  adjacent  motor 
areas  of  the  arm  or  of  half  of  the  body,  are  probably  Hkewise  involved. 
"When  the  cortical  center  or  the  upper  axons  are  involved,  the  paralysis 
is  on  the  opposite  side,  and  of  the  upper  neurone  type.  When  the  trunk 
of  the  nerve  is  affected,  the  paralysis  is  on  the  same  side  as  the  lesion 
and  is  of  the  lower  neurone  type."  Electrical  excitabiHty  is  preserved. 
In  peripheral  lesions  there  soon  occurs  muscular  wasting  and  complete 
loss  of  electric  response.  For  further  detail  standard  works  on  neu- 
rology must  be  consulted. 

The  prognosis  of  facial  paralysis,  due  to  cold,  is  generally  favorable. 
Paralysis  due  to  section  without  much  destruction  of  tissue  likewise 
offers  a  favorable  prognosis.  From  three  to  six  months  is  required  for 
regeneration  of  the  nerve.  Destruction  of  a  segment  of  }-i  or  }^  in.  of 
the  nerve,  or  the  presence  of  a  foreign  body  in  the  path  of  the  nerve, 
usually  prevents  regeneration.  The  prognosis  in  central  lesions  de- 
pends upon  the  degree  of  pressure  or  the  extent  of  degeneration. 

Treatment. — Surgical  intervention  is  indicated  in  certain  cases  of 
facial  paralysis,  especially  those  which  show  no  improvement  after 
the  first  six  months.  In  all  cases  of  facial  palsy,  attempt  should  be 
made  to  ascertain  the  etiological  factor.  If  paralysis  is  due  to  a  tumor 
or  other  mechanical  cause,  the  case  is  a  surgical  one  from  the  start. 
Further  progress  may  be  prevented  and  a  possible  cure  established  by 
removing  the  cause. 

Anastomosis  of  the  Facial  Nerve. — In  facial  paralysis  good  results 
have  been  obtained  by  implanting  the  spinal  accessory  or  the  hypo- 
glossal nerves  into  the  facial.     If  the  accessory  nerve  is  used,  a  good 


I  JO  REGIONAL    SURGERY 

result  usually  means  that  the  facial  muscles  of  the  patient  will  contract 
when  he  moves  his  shoulder.  Ballance,  Korte,  and  Frazier  therefore 
prefer  to  use  the  hypoglossal  because  the  nerve  centers  are  closer  and 
it  is  easier  to  improve  the  effect  by  education.  Both  end-to-end  and 
end-to-side  anastomoses  give  good  results.  The  latter  method  is  pref- 
erable where,  in  case  of  failure,  one  is  unwilling  to  risk  paralysis  of  the 
healthy  nerve  used  for  grafting. 

Operation. — "An  incision,  lo  cm.  long  {i.e.  longer  than  that  required 
for  simple  exposure  of  the  facial  nerve),  is  made  along  the  anterior 
border  of  the  sterno-mastoid  extending  up  to  the  mastoid  process.  The 
posterior  border  of  the  parotid  is  exposed  and  displaced  forward.  Ac- 
cording to  Frazier,  the  nerve  enters  the  gland  by  passing  forwards  on 
the  outer  surface  of  the  styloid  process  and  the  digastric  muscle  i  cm. 
above  and  the  same  distance  internal  to  the  tip  of  the  mastoid  process. 
When  the  lesion  is  situated  higher  up,  as  is  the  case  in  disease  of  the 
middle  ear,  and  in  which  degenerative  neuritis  has  been  proved  to 
exist  right  up  to  the  geniculate  ganglion  (Spiller),  the  nerve  must  be 
followed  to  the  styloid  foramen  and  divided  as  close  to  it  as  possible. 
The  hypoglossal  nerve  is  then  isolated  at  the  point  where  it  hooks 
round  the  commencement  of  the  external  carotid  artery."  (Kocher: 
Operative  Surgery,  Stiles,  231.)  The  distal  end  of  the  facial  nerve  is 
now  either  implanted  in  a  lateral  slit  in  the  hypoglossal  or  the  latter  is 
cut  across  and  its  proximal  segment  is  sutured  to  the  distal  segment 
of  the  facial  nerve.  The  sutures  ought  to  be  of  fine  catgut  and  should, 
if  possible,  only  involve  the  nerve  sheaths.  Oblique  division  of  the 
nerves  gives  a  broader  surface  of  contact. 

BIBLIOGRAPHY 

The  following  list  comprises  the  principal  authorities  consulted  in  the  prepara- 
tion of  this  chapter: 

AsmiURST:  Surgery  Principles  and  Practice,  1914. 

Binnie:  Operative   Surgery. 

Blair:  Surgery  and  Diseases  of  the  Mouth  and  Jaws. 

Bloodgood:  Surgery  Gynecology  and  Obstetrics,  April,  1914. 

Bourgeois  et  Lenormant:  Precis  de  pathologie  chirurgicale. 

British  Journal  of  Surgery,  April,  1914. 

DaCosta:  Modern  Surgery. 

Gelpke  und  Schlatter:  Lehrbuch  der  praktischen  chirurgie. 

Keen's  Surgery. 

Kocher:  Text-book  of  Operative  Surgery. 

LeDentu  et  Delbet:  Maladies  des  machoires. 


INJURIES    AND   DISEASES   OF    THE    FACE    AND    JAW  I?  I 

Matas:  Annals  of  Surgery,  Jan.,  1905. 
Morestin:  Affections  chirurgicale  de  la  face. 
Scudder:  Tumors  of   the  Jaws. 
SuaiMERS:  Modern  Treatment  of  Wounds. 
Thomson  and  Miles:  Manual  of  Surgery. 
WiJRDEMANN:  Injuries  of  the  Eye. 


SECTION  VIII 
OPERATIONS  FOR  TRIFACIAL  NEURALGIA 

By 
JOHN  FAIRBAIRN  BINNIE,  A.  M.,  C.  M.,  F.  A.  C.  S. 

INJECTIONS  INTO   NERVE  TRUNKS  IN  TRIFACIAL  NEURALGIA 

Solutions. — (a)  Alcohol  70-90  per  cent.  Quantity  injected  1-2 
cc.  (Levy,  Patrick),  {b)  Osmic  acid  2  per  cent.  Quantity  injected 
7-15  minims  (Murphy). 

Instrument. — The  Levy-Baudouin  cannula,  10  cm.  long,  i)^^'  mm. 
in  diameter  and  graduated  in  centimeters  (Fig.  99).  The  mandrin, 
when  pushed  home,  protects  the  sharp  point  and  so  avoids  injury  to 
arteries. 


Fig.  99. — Levy-Baudouin  cannula. 


Injection  of  Inferior  Maxillary  Nerve. — Introduce  the  cannula, 
mandrin  withdrawn,  at  the  middle  of  the  upper  edge  of  the  zygoma; 
push  it  directly  inward  until  it  strikes  the  squamous  portion  of  the 
temporal  bone  or  the  great  wing  of  the  sphenoid;  guided  by  contact 
with  these  bones  it  passes  inevitably  over  the  foramen  ovale  at  a  depth 
of '4  cm.  (i3^^  in.)  from  the  outer  surface  of  the  zygoma.  To  avoid 
injury  to  vessels  the  mandrin  may  be  pushed  home  when  a  depth  of 
1 3-^  cm.  is  reached  and  withdrawn  at  a  depth  of  4  cm.  A  characteristic 
pain  is  experienced  by  the  patient  when  the  nerve  is  touched.  Inject 
the  chosen  solution  slowly.  After  a  few  minutes  the  patient  has  a 
feeHng  of  stiffness,  swelUng  and  numbness  in  the  territory  of  the  in- 
jected nerve.  There  may  be  an  exacerbation  of  the  neuralgia  for  some 
hours.  As  a  rule,  the  injections  must  be  repeated  six  or  eight  times  at 
intervals  of  three  or  four  days. 

Injection  of  Superior  Maxillary  Nerve. — Draw  an  imaginary  line 
vertically  downward  from  the  external  angular  process  of  the  frontal 

173 


174  REGIONAL   SURGERY 

bone  across  the  zygoma.  On  this  Hne  introduce  the  cannula  im- 
mediately beneath  and  in  contact  with  the  lower  edge  of  the  zygoma  and 
pass  it  inward  and  a  trifle  upward  until  it  strikes  the  back  of  the  upper 
maxilla.  Guided  by  the  maxilla  push  the  needle  on  to  a  depth  of  43^^ 
cm.  (i^i  in.)  or  shghtly  more.  Its  point  is  now  at  the  foramen- 
rotundum. 

NEURECTOMY  FOR  TRIFACIAL  NEURALGIA 

Neurectomy  or  Avulsion  of  the  Supraorbital  Nerve. — ^Locate  the 
supraorbital  notch  or  foramen.  Make  a  horizontal  incision  parallel 
to  and  a  little  below  the  eyebrow.  Separate  the  fibers  of  the  orbicularis 
muscle.  Expose  the  nerve  as  it  emerges  from  the  bone;  isolate  it  for 
a  short  distance;  seize  the  nerve  trunk  in  the  jaws  of  a  fine  hemostat; 
rotate  the  forceps  so  that  the  nerve  becomes  wound  round  its  blades; 
reverse  the  direction  of  the  rotation.  By  alternately  rotating  slowly 
in  one  direction  and  then  in  the  other  it  is  possible  to  extract  most  of 
the  peripheral  portion  and  much  of  the  central  trunk  of  the  nerve.  Plug 
the  supraorbital  foramen  with  a  fragment  of  bone  or  a  metal  screw. 
Close  the  wound. 

Neurectomy  or  Avulsion  of  the  Second  Division  of  the  Fifth  Nerve 
(Superior  Maxillary  Nerve). — (A)  The  infraorbital  foramen  lies  about 
}^  in.  below  the  lower  margin  of  the  orbit  at  the  junction  of  its  inner  and 
middle  thirds,  i.e.,  on  a  line  drawn  from  the  supraorbital  notch  to  a 
point  between  the  two  bicuspid  teeth.  Expose  the  foramen  through 
a  cut  parallel  and  close  to  the  lower  orbital  margin  after  separating  the 
fibers  of  the  orbicularis.  Extract  the  nerve  by  the  same  method  as 
advised  for  the  supraorbital.  Plug  the  infraorbital  foramen  with  a 
fragment  of  bone  or  a  metal  screw.  This  operation  does  not  destroy 
the  alveolar  branches  of  the  nerve. 

(B)  Braun  and  Lossen's  Modification  of  Lucke's  Operation.  Ex- 
pose the  infraorbital  nerve  as  in  the  preceding  operation.  From  a 
point  just  below  and  behind  the  external  angular  frontal  process  make 
an  incision  backward  and  downward  to  near  the  tragus.  From  the 
same  point  cut  downward  and  forward  to  the  lower  margin  of  the 
zygoma.  Reflect  the  outHned  flap  downward.  Divide  the  zygoma 
anteriorly  and  posteriorly  and  turn  it  downward  after  dividing  the 
temporal  fascia  from  its  upper  edge.  Retract  the  tendon  of  the  tem- 
poral muscle  backward  and  expose  the  pterygo-maxillary  fossa  with 
its  fat  and  veins.     Push  the  fat  backward  with  a  blunt  retractor  thus 


OPERATIONS    FOR   TRIFACIAL   NEURALGL\  175 

protecting  the  venous  plexus  and  the  internal  maxillary  artery.  With 
a  strabismus  hook  locate  the  posterior  orbital  fissure  and  distinguish 
the  superior  maxillary  nerve  as  it  runs  inward,  forward  and  upward. 
Catch  the  nerve  in  forceps  or  by  a  ligature  and  divide  it  as  near  the 
foramen  rotundum  as  possible.  Pull  the  peripheral  end  of  the  nerve 
out  of  its  bony  canal.  Attend  to  hemostasis.  Replace  and  suture  the 
mobilized  segment  of  zygoma.     Close  the  wound. 

Neurectomy  of  the  Third  Division  of  the  Fifth  Nerve. — (A)  In- 
ferior Dental  Nerve. — Transmaxillary  Neurectomy.  From  the  angle 
of  the  lower  jaw  make  an  incision  for  about  i^j  in.  forward  along  the 
lower  border  of  the  jaw.  Separate  the 
masseter  from  the  bone.  Expose  most 
of  the  outer  surface  of  the  ascending  ra- 
mus. Apply  a  Doyen's  bur  to  the  bone 
midway  between  the  anterior  and  pos- 
terior margins  of  the  ramus  and  on  the 
level  of  the  free  border  of  the  teeth  of 
the  lower  jaw.  With  a  bur  open  the 
inferior  dental  canal  (Fig.  loo).     Avulse 

the   nerve.     Plug  the  canal  with  amal-  ^''^"' 

11,.  1  Fig.  100. — Excision  inferior  dental 

gam,   rubber   tissue   or   some  such  ma-  nerve.    {Lenormatit.) 

terial. 

B.  Neurectomy  of  the  Lingual  and  Inferior  Dental  Nerves. — 
Make  an  incision  through  the  skin  and  subcutaneous  tissue  alotte, 
from  the  middle  of  the  zygoma  backward  and  downward  to  a  point 
slightly  below  the  tragus.  Continue  the  cut  downward  along  the  pos- 
terior margin  of  the  ascending  and  then  forward  for  about  ^^  in.  along 
the  inferior  margin  of  the  horizontal  ramus  of  the  lower  jaw.  Reflect 
the  outhned  skin  flap  forward.  Note  the  position  of  Stenson's  duct  and 
of  the  anterior  part  of  the  parotid.  Make  an  incision  to  the  bone  below 
and  parallel  to  Stenson's  duct.  This  exposes  the  ascending  ramus  about 
}y'2  in.  below  the  sigmoid  notch.  Denude  the  bone  here  and  with  a 
^^-in.  trephine  penetrate  the  ramus.  The  upper  edge  of  the  trephine 
hole  must  not  be  more  than  }i  in.  below  the  notch.  With  forceps  nip 
away  the  bone  between  the  notch  and  the  trephine  opening.  Retract 
the  tendon  of  the  temporal  muscle  forward.  By  blunt  dissection 
demonstrate  the  external  pterygoid  muscle  passing  transversely  across 
from  the  external  pterygoid  plate  to  the  articular  process  of  the  lower 
jaw.  Recognize  the  internal  pterygoid  muscle  passing  downward 
and  backward  from  the  pterygoid  fossa  to  the  inner  surface  of  the  lower 
jaw  near  its  angle.  Retract  the  external  pterygoid  upward  and  so 
expose  the  lingual  and  inferior  dental  nerves  coming  down  from  under 


176  REGIONAL   SURGERY 

it  and  resting  on  the  internal  pterygoid.  Either  avulse  the  nerves  or 
trace  them  to  the  foramen  ovale  and  divide  them  there.  Extract  as 
much  of  the  peripheral  part  of  the  nerves  as  possible.  Attend  to 
hemostasis.     Close  the  wound. 

Cushing's  Operation  on  the  Gasserian  Ganglion. — From  a  point 
}/2  in.  behind  and  slightly  above  the  external^angle  of  the  frontal  bone 
make  a  curved  incision  to  the  zygoma  immediately  in  front  of  the 
ear.  The  highest  point  of  this  incision  is  2  in.  above  the  zygoma. 
Reflect  the  skin  downward.  Subperiosteally  resect  the  zygoma.  Re- 
flect downward  a  flap  of  temporal  fascia  and  muscle  corresponding  to 
the  skin  flap.  With  a  burr  penetrate  the  most  prominent  part  of  the 
great  wing  of  the  sphenoid.  Enlarge  the  bone  opening  until  it  is 
1 3^  in.  in  diameter  and  extends  down  to  and  includes  the  ridge  between 
the  temporal  and  zygomatic  fossae.  Lift  the  dura  and  the  middle  menin- 
geal artery  from  the  base  of  the  skull  until  the  attachment  of  the  dura 
to  the  foramen  is  reached.  Support  the  dura  and  its  contents  gently 
with  a  spatula.  Guided  by  the  inferior  maxillary  nerve,  split  the  sheath 
of  the  ganghon  to  expose  its  upper  surface.  Bluntly  isolate  the  three 
divisions  of  the  trigeminus.  Isolate  the  ganglion  and  its  sensory  root. 
Lift  the  peripheral  divisions  with  a  blunt  hook  and  divide  them. 
Avulse  the  sensory  root.  Temporary  pressure  exerted  at  intervals 
during  the  operation  serves  to  control  hemorrhage.  Provide,  if  neces- 
sary, drainage  by  means  of  rubber  tissue.  Close  the  wound,  anatomic- 
ally, in  layers.     Remove  the  drain,  if  such  is  used,  in  48  hours. 

Abbe  performs  a  similar  operation  but  does  not  attack  the  ganglion. 
He  divides  the  nerves  intracranially  and  prevents  their  reunion  by 
implanting  sterile  rubber  tissue  over  the  cranial  openings. 


SECTION  IX 
OPERATIONS  UPON  THE  JAWS^ 

By 
JOHN  FAIRBAIRN  BINNIE,  A.  M..  C.  M.,  F.  A.  C.  S. 

EXCISION  OF  THE  ALVEOLAR  PROCESS 

A.  Excision  of  Tumors  of  the  Alveolus  of  the  Lower  Jaw. — If  the 
disease  is  very  limited  one  may,  by  using  a  large  rongeur  forceps,  re- 
move it,  along  with  a  safe  margin  of  healthy  bone,  in  one  bite.  If 
the  disease  is  more  extensive  it  is  better  to  make  an  incision  through 
the  muco-periosteum  down  to  the  bone  all  round  and  at  a  safe  distance 
from  the  disease.  With  a  drill  bore  holes  through  the  alveolus  along 
the  line  of  incision.  These  holes  should  be  from  }i  to  ^i  in.  apart. 
It  is  now  easy  to  remove  the  diseased  segment  of  bone  with  a  chisel 
or  bone-cutting  forceps.  Unless  the  jaw  is  weakened  by  some  means 
such  as  that  described  it  is  difficult  to  cut  any  considerable  part  of  it 
without  producing  a  fracture. 

Hemorrhage  is  stopped  by  means  of  packing  or  by  the  use  of  the 
actual  cautery.  After-treatment  consists  of  keeping  the  mouth  as 
clean  as  possible  by  means  of  antiseptic  washes  and  of  encouraging 
the  patient  to  sit  up  at  the  earliest  possible  moment.  Posture  is  a 
great  factor  in  the  prevention  of  post-operative  pneumonia. 

B.  Excision  of  Tumors  of  the  Alveolus  of  the  Upper  Jaw. — The 
methods  advised  in  the  case  of  the  lower  jaw  may  also  be  employed 
for  the  upper. 

When  much  of  the  alveolus  is  involved  and  perhaps  part  of  the  palate 
(carcinoma,  sarcoma).  Schlange  advocates  the  following  operation: 
Provide  several  (three  to  four)  gouges  with  blades  i  to  2  in.  wide. 
Tampon  the  nostril  on  the  diseased  side.  To  afford  access  to  the  mouth 
it  may  be  necessary  to  split  the  cheek  with  a  curved  incision  running  from 
the  angle  of  the  mouth  outward  and  upward.  "Retract  the  upper  Up 
and  cheek  strongly  upward.  Open  the  jaws  widely  with  a  gag.  Along  a 
line  as  remote  as  possible  from  the  tumor  drive  the  gouges,  one  after 
the  other,  vertically  upward  through  the  alveolar  and  palatine  processes 
*  See  also  p.  193  et  seq. 

12  177 


iy8  REGIONAL    SURGERY 

into  the  antrum.  In  order  to  see  what  one  is  doing  it  is  best  to  work 
from  behind  forward.  The  gouges,  and  this  is  important,  must  be  left 
undisturbed  in  situ  until  the  end  of  the  resection  because  their  with- 
drawal would  permit  severe  bleeding.  When  the  horizontal  portion 
of  the  superior  maxilla  has  been  thus  divided  by  three  gouges  the  part 
to  be  removed  is  now  held  in  place  by  the  anterior  wall  of  the  antrum 
alone.  The  fourth  gouge  quickly  divides  the  connection,  when  a  slight 
leverage  exerted  through  the  chisels  causes  the  separated  bone  to  come 
away.  Before  the  gaping  wound  has  time  to  bleed  it  is  thoroughly 
packed  with  a  tampon  or  large  sponge  which  has  been  held  in  readi- 
ness. The  operation  can  be  carried  out  in  a  few  minutes  and  with 
almost  no  loss  of  blood." 

C.  Excision  of  the  Lower  Jaw. — Usually  only  one-half  of  the  lower 
jaw  is  removed.  Make  an  incision  parallel  to  and  a  little  below  the  lower 
edge  of  the  horizontal  ramus  of  the  jaw,  from  the  symphysis  to  the 
angle.  If  necessary  continue  the  cut  upward  along  the  posterior  edge 
of  the  ascending  ramus  to  a  point  about  one  finger-breadth  below  the 
lobe  of  the  ear.  Expose,  tie  and  divide  the  facial  vessels.  If  necessary 
to  obtain  free  access  to  the  bone,  make  a  vertical  incision  in  the  middle 
of  the  chin  reaching  from  the  horizontal  incision  to  a  point  a  little  be- 
low the  red  margin  of  the  lower  lip.  (If  is  well  to  avoid  division  of  the 
lip  itself.)  Working  through  the  incisions  described,  dissect  the  soft 
parts  free  from  the  outer  side  of  the  bone  to  be  removed.  If  the 
operation  is  for  the  removal  of  a  tumor,  sacrifice  the  periosteum. 
Choose  the  line  in  which  the  bone  must  be  divided  anteriorly.  Sepa- 
rate the  soft  parts  from  the  inner  surface  of  the  bone  along  this  hne. 
Remove  any  teeth  which  may  interfere  with  section  of  the  bone.  Di- 
vide the  bone  with  a  Gigli  saw.  With  a  lion-jawed  forceps  pull  the  bone 
downward  and  outward  and  separate  the  soft  parts  from  the  inner  sur- 
face of  the  bone.  Pull  the  fragment  of  jaw  downward  and  divide  the 
attachments  of  the  temporal  muscle  to  the  coronoid  process.  (It  may 
be  easier  to  divide  the  coronoid  process  with  a  bone  forceps  and  leave 
it  in  situ.)  By  a  twisting  movement  tear  the  head  of  the  bone  from 
its  articulation.  Attend  to  hemostasis.  If  possible  suture  the  mucosa 
of  the  floor  of  the  mouth  to  that  of  the  cheek.  Close  the  external 
wound  after  providing  for  drainage. 

After-treatment  consists  of  endeavoring  to  keep  the  mouth  as  clean 
as  possible,  giving  nourishment  and  encouraging  the  patient  to  sit 
up  and  move  about  at  the  earliest  possible  date.  If  it  is  not  neces- 
sary to  remove  the  ascending  ramus  of  the  jaw  the  operation  is  much 


OPERATIONS   UPON   THE   JAWS  1 79 

simpler,  the  bone  being  divided  behind  as  well  as  in  front  of  the  diseased 
segment. 

When  one-half  of  the  lower  jaw  or  any  complete  segment  of  it  has 
been  removed,  much  deformity  results  as  the  remainder  cannot  main- 
tain its  normal  position.  The  hiatus  in  the  bone  may  be  filled  by  a 
strong  wire,  by  a  bar  of  hard  rubber  (vulcanite)  or  a  segment  of  rib  may 
be  implanted  after  the  wound  has  healed  and  asepsis  can  be  assured. 

D.  Excision  of  the  Upper  Jaw. — It  has  been  shown  that  excision 
of  the  superior  maxilla  has  had  a  large  death  rate  since  the  anaesthetic 
era  (Kronlein,  Archiv  f.  khn.  Chir.,  LXIV).  The  commonest  cause  of 
death  has  been  pneumonia  and  even  the  use  of  tracheotomy  with  the 
Trendelenburg  or  Hahn's  cannula  has  not  greatly  improved  matters. 
To  avoid  these  dangers  Fritz  Konig  and  others  perform  the  operation 
under  combined  infiltration  and  conduction  anaesthesia.  Most  sur- 
geons still  use  a  general  anaesthetic.  To  avoid  hemorrhage  and  to  gain 
access  to  the  lymph  glands  it  is  wise  to  tie  the  external  carotid  artery. 
Some  surgeons  temporarily  occlude  the  common  carotid  by  means  of 
Crile's  clamp  or  a  tape.  If  a  general  anaesthetic  is  used,  Butlin's 
laryngotomy  is  of  much  value  and  will  be  described  as  part  of  the 
operation. 

Ligation  of  the  External  Carotid  Artery. — Place  the  patient  on  his 
back  with  head  moderately  extended  and  rotated  toward  the  opposite 
side.  Make  an  incision  i3-^  to  3  in.  in  length  along  the  anterior  margin 
of  the  sterno-mastoid  and  having  its  center  opposite  the  greater  horn 
of  the  hyoid  bone.  Divide  the  platysma  and  the  deep  fascia  immediately 
in  front  of  the  sterno-mastoid  throughout  the  length  of  the  wound. 
Retract  the  sterno-mastoid.  Find  the  posterior  belly  of  the  digastric 
muscle  in  the  upper  part  of  the  wound,  and  the  hypoglossal  nerve  a 
little  below  the  digastric.  Retract  these  structures  upward.  Note  the 
tip  of  the  greater  horn  of  the  hyoid  and  expose  the  external  carotid 
opposite  it.  Demonstrate  at  least  one  of  the  branches  of  the  vessel 
before  ligating  because  neglect  of  this  simple  precaution  has  permitted 
the  internal  to  be  mistaken  for  the  external  carotid.  Open  the  sheath 
and  pass  a  Hgature  around  the  vessel  from  without  inward  thus  avoid- 
ing the  vein  lying  to  the  outer  side  of  and  frequently  overlapping 
the  vessel  and  thus  avoiding  also  the  superior  laryngeal  nerve  behind 
the  artery. 

Note  if  there  are  any  enlarged  lymphatics.  Such  may  be  removed 
through  the  wound.  Attend  to  hemostasis.  Close  the  wound  and 
apply  a  collodion  dressing. 


i8o 


REGIONAL    SURGERY 


Preliminary  Laryngotomy. — Place  the  patient  on  his  back,  head 
thrown  back  and  neck  supported  by  a  firm  pillow.  Make  a  median 
incision  i3^^  in.  long  over  the  lower  part  of  the  thyroid,  the  crico- 
th>Toid  space  and  the  cricoid.     Retract  the  edges  of  the  wound  and  ex- 


FiG.   loi. — Butlin's  laryngotomy  cannula. 

pose  the  crico-thyroid  membrane.  Divide  the  crico-thyroid  membrane 
transversely  close  to  the  cricoid  cartilage  so  as  to  avoid  injuring  the 
vocal  cords  and  crico-thyroid  vessels.  Be  sure  to  penetrate  the  mucosa. 
Enlarge  the  mucosal  wound  by  stretching  it  with  a  sinus  forceps  or 
hemostat.  Introduce  Butlin's  cannula  (Fig.  loi)  on  its  guide.  Remove 
the  guide.  Fix  the  cannula  in  place  by  means  of  a 
tape  round  the  neck.  It  is  easy  to  continue  ad- 
ministering the  anaesthetic  through  the  cannula. 
Pack  the  pharynx  with  a  sponge  or  pad  of  gauze. 
Expose  the  upper  jaw  by  Weber's  or  Velpeau's  in- 
cision (Fig.  102).  The  former  is  preferable.  If 
Weber's  incision  is  chosen,  reflect  the  flap  ABCD 
outward,  cutting  close  to  the  bone.  Separate  the 
periosteum  covering  the  floor  of  the  orbit  from  the 
bone.  Gently  lift  the  orbital  contents  upward 
Fig.  102.— ABCD,  with  a  flat  retractor.     With  a  Gigli's  saw  or  bone 

"Y^gl^gj-'g  incision '   PV  /    •  \         • 

Velpeau's  incision.  '  forccps  divide  the  bone  at  X  and  Z  (Fig.  103)  or  if 
a  more  extensive  resection  is  required  at  X,  P  and 
Q.  Open  the  patient's  mouth  and  with  a  knife  make  a  cut  through 
the  muco-periosteum  of  the  palate  close  and  parallel  to  the  middle 
line;  continue  this  cut  forward  through  the  muco-periosteum  cover- 
ing the  alveolus  and  to  the  nasal  aperture.     With  Gigli's  saw  or  a 


OPERATIONS    UPON   THE    JAWS 


i8i 


bone  forceps  divide  the  alveolus  (Y)  and  hard  palate  along  the  line 
of  incision.  With  a  knife  or  scissors  cut  the  soft  palate  from  the  hard 
palate  on  the  side  being  removed.     Using  Hon-jaw  forceps  remove  the 


Fig. 


103. — Excision  of  upper  jaw.     A',   Y,  Z,  Usual  lines  for   division  of   bone, 
section  may  be  made  here  instead  of  at  Z,  when  disease  is  extensive.^ 


P-Q-r 


jaw  by  a  twisting  motion.     If  the  internal  maxillary  artery  is  found 
bleeding,  catch  it  in  forceps  and  ligate  it.     Pack  the  wound  with  iodo- 
form gauze  or  its  equivalent.     Replace  the  flap  of  soft  parts  and  insert 
sutures.     Remove  the  pharyngeal  pack  and  when 
the  patient  is  in  bed  remove  the  laryngeal  can- 
nula if  such  has  been  used. 

After-treatment. — Until  he  is  thoroughly  "out" 
of  the  anaesthetic  the  patient  ought  to  be  kept 
in  the  Trendelenburg  position  or  at  least  with 
his  head  low  and  l>ing  on  the  side  operated 
upon.  As  soon  as  possible  he  must  sit  up  in 
bed  or  a  chair.  The  mouth  should  be  frequently 
rinsed  with  mild  antiseptic  solutions  and  liquid 
nourishment  should  be  given  through  a  soft 
catheter  passed  into  the  oesophagus.  The  pack- 
ing may  be  left  in  situ  for  several  days  and  then  only  gradually  re- 
moved. When  recovery  is  accomplished  consult  a  good  dentist  wdth 
regard  to  the  use  of  an  artificial  palate. 

If  the  operation  has  been  undertaken  for  sarcoma  the  disease  may 
extend  through  the  infundibulum  into  the  frontal  sinus  (Keen)  in  which 


Tig.  104. — F.  Konig's 
operation. 


152  REGIONAL   SURGERY 

case  the  anterior  wall  of  the  infundibulum  and  the  inferior  wall  of  the 
sinus  should  be  removed  with  fine  rongeurs  and  the  tongue-shaped 
process  of  the  sarcoma  wiped  away. 

When  it  has  been  necessary  to  remove  the  floor  and  the  outer  wall 
of  the  orbit,  Fritz  Konig  advises  rebuilding  the  orbital  floor  as  follows: 
Recognize  and  expose  the  temporal  muscle.  SpHt  the  muscle  upward 
and  downward  about  i^-o,  finger-breadths  behind  its  anterior  margin 
and  at  the  level  of  the  coronoid  process.  With  a  chisel  divide  the  as- 
cending ramus  of  the  lower  jaw  along  the  line  in  which  the  muscle  was 
spHt  (Fig.  104).  By  a  transverse  cut  in  the  bone  mobilize  the  flap 
consisting  of  temporal  muscle  and  part  of  the  ascending  ramus.  Turn 
this  flap  inward  and  unite  its  free  extremity  to  the  remnants  of  the 
frontal  process. 


SECTION  X 
DISEASES  OF  THE  BUCCAL  CAVITY 

By 
Sir  H.  L.  MAITLAND,  M.  Ch.,  M.  B. 

Lecturer  in  Clinical  Surgery,  Sydney  University;  Examiner  in  Clinical  Surgery,  Sydney  University 

Hon.  Consulting    Surgeon,    The   Coast  Hospital;  Hon.  Consulting  Surgeon,    Women's 

Hospital;  Hon.  Surgeon,  Sydney  Hospital;  Senior  Hon.  Surgeon, 

South  Sydney  Hospital. 

Sydney,  New  South  Wales. 

STOMATITIS 

This  term  is  applied  to  any  inflammatory  condition  of  the  buccal 
mucous  membrane. 

There  are  four  varieties: 

1.  Catarrhal  stomatitis. 

2.  Aphthous  Stomatitis. 

3.  Ulcerative  stomatitis. 

4.  Gangrenous  stomatitis  or  noma. 

Catarrhal  stomatitis  is  characterized  by  simple  redness  and  sore- 
ness of  the  buccal  mucous  membrane;  a  slight  degree  of  swelHng  is 
present  accompanied  by  an  excessive  exudation  of  viscid  mucous 
secretion.  Any  agent  which  acts  as  an  irritant — such  as  the  excessive 
use  of  alcohol  or  tobacco,  the  cutting  of  teeth  in  children,  carious  teeth 
and  wounds — may  give  rise  to  this  condition. 

The  removal  of  the  cause  quickly  remedies  the  condition.  Ab- 
stinence from  irritating  foods,  and  the  use  of  a  non-irritating  mouth- 
wash is  all  that  is  usually  required  in  the  way  of  treatment. 

Aphthous  stomatitis  is  characterized  by  the  appearance  upon  the 
mucous  membrane  of  patches,  variable  in  size,  which  are  at  first 
vividly  red:  later  they  become  yellowish  in  color,  owing  to  the  pres- 
ence of  a  fibrinous  exudate  into  the  superficial  layers  of  the  mucous 
membrane. 

The  patches  vary  in  number,  and  show  a  tendency  to  coalesce. 

The  epithelium  overlying  them  is  soon  shed,  leaving  red  spots, 
which  gradually  disappear. 

In  the  first  few  days  after  the  appearance  of  the  patches  there  is 

1S3 


184  REGIONAL    SURGERY 

some  pain,  salivation,  foetor  of  breath  and  fever.  The  disease  is 
contagious,  and  is  seen  most  frequently  in  the  underfed,  unhealthy- 
children  of  the  poor. 

TreaUnent  consists  of  plenty  of  fresh  air,  proper  feeding  and  bland 
mouth- washes.  If  the  case  be  a  severe  one,  paint  the  patches  with  a 
2  per  cent,  solution  of  silver  nitrate,  and  give  chlorate  of  potash 
internally. 

Ulcerative  Stomatitis. — The  cause  of  this  disease  has  not  been 
definitely  determined.  The  one  constant  etiological  factor  is  the 
presence  of  teeth  in  the  mouth.  The  gums  around  the  teeth  are  first 
affected,  and  only  later  does  extension  to  the  rest  of  the  mucous  mem- 
brane take  place. 

This  disease  is  most  commonly  seen  in  debilitated  children,  during 
either  the  first  or  second  dentition.  Living  under  bad  hygienic  con- 
ditions is  a  contributing  factor.  Under  similar  conditions  it  may 
occur  among  adults,  when  they  are  crowded  together  in  ships  and  in 
armies.  It  may  also  occur  in  such  syphilitic  subjects  as  are  susceptible 
to  the  action  of  mercury,  or  in  those  whose  dosage  of  that  drug  has  been 
too  liberal. 

The  gums  along  the  canines  and  the  incisors  are  usually  first  af- 
fected, becoming  red  in  color  and  swollen,  and  bleeding  readily  on  pres- 
sure. These  symptoms  are  accompanied  by  a  marked  feehng  of  malaise. 
The  breath  becomes  extremely  foetid,  and  there  is  profuse  salivation. 
Ulceration  begins,  and  may  progress  along  the  free  edge  of  the  gums,  and 
the  teeth  may  become  surrounded  by  ulcerated  areas  covered  with  a 
diphtheritic  exudate.     The  teeth  become  loose,  and  fall  out. 

The  ulceration  may  extend  to  the  inner  aspect  of  the  cheek,  Hps 
and  tongue.  The  lymphatic  glands  in  the  neck  become  infected  and 
swollen.  The  faucial  isthmus  limits  the  disease,  and  the  ulceration 
rarely  appears  on  either  the  hard  or  the  soft  palate. 

In  severe  cases  osteomyelitis  of  the  alveolar  border  may  follow^ 
ushered  in  by  a  high  temperature  and  other  symptoms  of  sepsis;  por- 
tions of  the  bone  may  necrose,  and  pulmonary  complications  may  end 
the  case  fatally. 

Treatment. — The  patient  should  be  placed  under  the  best  hygienic 
conditions,  and  kept  out  of  doors,  if  the  weather  permits.  There  are 
few  diseases  which  benefit  more  from  a  life  in  the  open. 

As  mastication  is  painful,  Hquid  food  only  can  be  given.  It  should 
be,  however,  sufficient  in  amount,  and  varied  in  kind.  It  may  be 
necessary  to  feed  the  patient,  if  a  child,  forcibly.     Painting  the  gums 


DISEASES    OF   THE  BUCCAL   CAVITY  185 

with  a  2  per  cent,  solution  of  eucaine,  before  feeding,  lessens  the  pain 
of  mastication. 

If  the  teeth  become  loose,  they  should  be  left  alone;  they  may 
tighten  when  recovery  takes  place. 

Exceptional  cleanHness  of  the  mouth  is  essential,  and  the  frequent 
use  of  mild  antiseptic  washes  is  indicated;  a  lo  per  cent,  solution  of 
hydrogen  peroxide  is  probably  the  best.  It  is  wise,  however,  not  to 
continue  this  drug  for  more  than  three  or  four  days. 

Gangrenous  Stomatitis  or  Noma. — This  disease  is  characterized 
by  a  progressive  and  destructive  form  of  gangrene  involving  the  buccal 
cavity,  and  attacking  by  preference  the  cheek,  less  often  the  gums, 
palate  and  lips. 

The  disease  is  most  common  in  children  between  the  ages  of  two  and 
twelve  who  have  been  debilitated  by  one  of  the  acute  specific  fevers,  es- 
pecially measles.  It  appears  also  in  syphihtic  infants  who  have  been 
mercuriahzed;  in  fact  it  may  make  its  appearance  in  children  after  any 
acute  illness,  if  they  be  living  under  unfavorable  conditions.  In  a  few 
cases  the  disease  has  been  observed  in  adults,  and  in  such  it  has  begun 
as  an  ulcerative  stomatitis. 

The  high  mortality  of  this  disease  makes  its  preventive  treatment 
in  specific  fevers  of  the  utmost  importance. 

Symptoms. — The  marked  symptoms  of  the  disease  are  preceded 
by  inflammation  of  the  oral  mucous  membrane.  Then  on  the  inside 
of  the  cheek  a  vesicle  filled  with  bloody  serum  makes  its  appearance. 
This  characteristic  symptom  may  sometimes  appear  on  the  muco- 
periosteum  of  the  alveolar  process  or  on  the  hard  palate. 

The  vesicle  in  a  few  hours  is  replaced  by  a  patch  of  gangrene,  which 
is"surrounded  by  a  considerable  amount  of  inflammatory  induration. 
The  cheek  becomes  swollen;  a  shiny,  white  patch  appears  upon  the  skin, 
becomes  gangrenous,  and  perforation  of  the  cheek  takes  place.  The 
gangrene  extends  rapidly  and  is  accompanied  by  extensive  sloughing; 
the  whole  of  the  cheek  becomes  indurated,  and  the  rest  of  the  face 
oedematous  and  swollen;  as  the  sloughing  process  extends,  the  odor 
from  the  necrotic  tissue  becomes  extremely  offensive.  The  gangrenous 
process  may  extend  to  the  bones  of  the  jaw.  The  more  acute  the 
process,  the  more  rapidly  death  supervenes  from  septic  infection  and 
broncho-pneumonia. 

The  exact  pathology  of  the  disease  is  obscure,  since  the  specific 
microorganism  has  not  been  definitely  isolated.  The  streptococcus 
pyogenes  is  regarded  by  some  as  the  active  agent  in  its  causation.     By 


1 86  REGIONAL    SURGERY 

Others  the  streptothrix  of  noma,  isolated  by  Perthes,  is  regarded  as  the 
cause. 

This  disease  is  less  frequently  encountered  on  the  mucosa  of  the 
anus  and  vulva. 

Treatment,  to  be  effective,  must  be  prompt.  The  whole  of  the 
gangrenous  area  must  be  freely  removed.  Since  the  knife  would  open 
up  tissue  spaces,  as  well  as  giving  rise  to  some  loss  of  blood,  it  is  probably 
better  to  do  this  with  the  thermo-cautery. 

It  has  been  observed  that  early  perforation  of  the  cheek  is  not 
uncommonly  followed  by  a  favorable  ending  to  the  case.  This  observa- 
tion shows  that  the  removal  of  the  gangrenous  area  should  extend 
through  the  entire  thickness  of  the  cheek. 

The  local  treatment  should  include  frequent  lavage  of  the  mouth 
and  affected  area  with  strong  solutions  of  peroxide  of  hydrogen. 
Every  effort  should  be  made  to  keep  up  the  general  health  with  liberal 
diet,  good  hygienic  conditions  and  tonics. 

Alveolar  Abscess. — Suppuration  may  occur  beneath  the  muco- 
periosteum  of  the  jaws  or  palate.  It  usually  arises  as  follows:  a  tooth 
becomes  carious,  its  pulp  is  affected,  and  the  infection  travels  down  the 
root-canal  and  through  the  apical  foramen  into  the  tooth-socket; 
the  pus  formed,  being  in  a  confined  space,  escapes  beneath  the  muco- 
periosteum  and  forms  an  alveolar  abscess.  If  it  arises  in  connection 
with  the  upper  incisor  teeth,  the  pus  may  travel  beneath  the  muco- 
periosteum  along  the  hard  palate,  giving  rise  to  a  prominent  fluctuating 
swelling  covered  with  a  red,  swollen  and  tender  muco-periosteum.  -  If 
the  abscess  occurs  in  connection  with  the  second  upper  bicuspids  and 
upper  molars,  the  pus  may  perforate  into  the  submucous  tissue  of 
the  antrum  and  infect  that  cavity.  An  alveolar  abscess  may  also  have 
its  origin  in  the  impaction  of  a  foreign  body  (such  as  a  fish  bone  in  the 
mucous  membrane)  or  may  follow  a  wound. 

Treatment  consists  in  opening  the  abscess  and  treating  the  cause, 
and  in  the  employment  of  antiseptic  mouth-washes. 

Angina  Ludowici. — Phlegmonous  celluHtis  of  the  floor  of  the  mouth 
has  been  named  after  Ludwig  of  Stuttgart,  who  was  the  first  to  describe 
in  detail  the  condition.  The  space  between  the  symphysis  of  the  jaw 
and  the  muscles  of  the  floor  of  the  mouth  is  filled  up  by  a  layer  of 
loose  connective  tissue,  which  contains  the  ducts  of  the  sublingual 
and  submaxillary  glands.  The  disease  is  an  infection  of  this  connec- 
tive tissue. 


DISEASES    or    THE   BUCCAL   CAVITY  1 87 

The  condition  may  arise  from  wounds  of  the  mouth,  carious  teeth, 
and  ulcers.  A  common  cause  is  the  formation  of  an  abscess  from 
necrosis  due  to  the  pressure  of  an  impacted  wisdom  tooth. 

The  pathology  of  the  disease  is  practically  identical  with  that  of 
erysipelas,  the  offending  organisms  being  the  streptococcus  and  the 
staphylococcus  aureus. 

The  symptoms  are  of  the  greatest  severity,  and  are  alarmingly  rapid 
in  their  development.  A  hard  mass  develops  on  the  floor  of  the  mouth, 
between  the  lower  jaw  and  the  hyoid  bone.  In  a  few  hours  the  swelling 
rapidly  extends  to  the  neck  and  face.  The  swelling  is  indurated, 
brawny  and  red  in  color.  The  tissues  beneath  the  tongue  become 
greatly  swollen  and  cedematous.  The  swelling  may  extend  to  the 
larynx,  so  that  respiration  is  impeded  by  oedema  of  the  glottis;  or  it  may 
extend  down  from  the  neck  on  to  the  chest  or  into  the  anterior  medias- 
tinum. Accompanying  the  local  condition  are  constitutional  symptoms 
of  marked  sepsis. 

Treatment. — Two  main  lines  of  treatment  are  indicated. 

1 .  Recognize  the  primary  focus  from  which  the  disease  is  spreading, 
and  vigorously  attack  it. 

If  an  abscess  of  the  jaw  from  an  impacted  tooth  be  the  Jons  et  origo 
mali,  remove  the  tooth,  open  the  abscess,  and  drain  the  cavity.  Ulcers 
and  wounds,  if  they  be  the  cause,  should  be  treated  on  general  principles 
properly  planned. 

2.  By  incisions  provide  free  drainage  of  the  cellular  planes. 

If  the  infection  be  mild,  and  above  the  omo-hyoid,  the  incision  may 
be  made  into  the  floor  from  within  the  mouth. 

If  the  infection  be  virulent,  and  the  brawny  induration  extend  below 
the  jaw,  then,  to  provide  proper  drainage,  the  incisions  must  be  made 
from  the  outside  in  the  following  way: 

A  vertical  incision  is  made  from  the  point  of  the  chin  to  the  hyoid 
bone;  lateral  incisions,  if  necessary,  are  then  made  from  the  point  out- 
ward by  dissection.  The  cellular  planes  above  the  mylohyoid  are  opened 
and  drained.  It  is  expedient  in  most  cases  to  open  up  freely  the  fascial 
compartment  containing  the  submaxillary  glands  on  either  one  or  both 
sides,  according  to  the  extent  of  the  induration.  The  advantage  of  this 
procedure  is  that  not  only  is  free  drainage  provided,  but  the  upward 
pressure  on  the  floor  of  the  mouth  is  considerably  relieved.  The  in- 
cision, when  healed,  lies  well  under  the  jaw.  If  the  inflammatory 
process  has  extended  lower  down  the  neck,  conveniently  planned  in- 
cisions must  be  made  to  provide  drainage.     Respiratory  embarrass- 


1 88  REGIONAL   SURGERY 

ment  from  oedema  of  the  glottis  must  be  watched  for  and  relieved 
by  tracheotomy. 

Prompt  and  energetic  treatment  in  these  cases  will  materially  lessen 
the  possibility  of  a  fatal  issue. 

SYPHILIS  OF  THE  MOUTH 

Primary. — The  mucous  membrane  of  the  mouth  is  not  an  un- 
common site  of  the  extragenital  chancre.  Infection  takes  place  (in 
order  of  frequency)  on  the  lips,  tongue,  palate,  cheek  and  gums. 

The  initial  form  of  the  disease  is  a  small  superficial  ulcer  with  a 
smooth  bright-red  base  and  indurated  edges.  There  is  marked  enlarge- 
ment of  the  lymphatic  glands  in  the  draining  areas  in  the  neck.  The 
enlargement  is  more  extensive,  and  takes  place  much  more  rapidly  than 
does  involvement  of  the  glands  in  a  genital  chancre. 

Secondary  Syphilitic  Lesions. — First.  An  erythema  or  diffuse  red- 
ness, involving  by  preference  the  mucous  membrane  of  the  soft  palate 
and  pharynx;  its  appearance  is  usually  coincident  with  that  of  a  roseol- 
ous  rash.  The  only  characteristic  points  about  this  lesion  are  its  pro- 
tracted presence,  and  its  susceptibility  to  antisyphilitic  treatment. 

Second.  Papulce.— This  form  may  appear  anywhere  on  the  buccal 
mucous  membrane.  The  papules  are  usually  about  the  size  of  a  pea, 
and  are  distinguished  by  their  pale-gray  color,  which  is  due  to  the 
maceration  by  saliva  of  the  superficial  hypertrophied  epithelium. 
This  destruction  of  epithelium  may  go  so  far  that  a  superficial  ulcer  is 
formed.  On  the  other  hand,  if  the  epithelium  thickens  and  the  papule 
develops,  a  picture  is  presented  similar  to  the  broad,  raised,  flat  condy- 
lomata found  around  the  anal  and  genital  clefts. 

The  appearance  of  these  papules  just  inside  the  lips  is  quite  charac- 
teristic. In  the  angle  is  a  pale-gray  papule,  involving  both  com- 
missures, and  fissured  at  the  angle.  The  fissure  is  very  sensitive  and 
bleeds  easily. 

Tertiary  Lesions. — Surgically,  the  tertiary  lesions  of  syphilis  are 
of  more  importance. 

The  appearance  of  gummata  in  the  buccal  cavity  usually  takes 
place  after  the  fifth  year.     Men  are  more  often  affected  than  women. 

Syphilis  of  the  tongue  is  described  elsewhere. 

The  gummata  are  frequently  multiple,  and  may  appear  anywhere  in 
the  mouth. 

The  hard  palate  is  more  often  the  seat  of  these  later  lesions  than 


DISEASES    OF   THE   BUCCAL   CAVITY  189 

any  other  part  of  the  buccal  cavity.  The  lesion  begins  in  the  middle 
line,  and  leads  to  perforation  of  the  palatine  process  of  the  superior 
maxilla.  It  is  sometimes  possible  to  remove  the  resulting  sequestrum 
through  the  nose,  leaving  the  mucous  membrane  covering  the  palate 
intact.  The  gumma,  unless  influenced  by  treatment,  always  leads  to 
perforation  and  destruction  of  the  palate. 

The  cheek  at  the  lip  angle  and  the  floor  of  the  mouth  are,  in  this 
order  of  frequency,  the  next  most  common  sites.  In  the  first-named 
situation  a  circumscribed  hard  induration  appears,  which  may  extend 
and  involve  the  lip,  or  may  perforate  the  cheek  at  the  angle  of  the 
mouth.  This  condition  may  be  mistaken  for  carcinoma;  but  extensive 
syphihtic  lesions  in  this  situation  are  usually  accompanied  by  signs  of 
syphilis  elsewhere. 

Treatment. — The  usual  constitutional  remedies  are  mainly  depended 
upon. 

TUBERCULOSIS  OF  THE  ORAL  CAVITY 

As  a  primary  affection  this  is  extremely  rare.  It  is  more  common 
as  a  secondary  affection,  and  as  such  may  be  generated  in  three  ways: 

1.  By  direct  extension  from  lupus. 

2.  By  tuberculous  sputum  from  the  lung  or  larynx. 

3.  From  the  blood-stream  (haemic  infection). 

Lupus  may  extend  from  the  lip  to  the  mouth,  or  from  the  nose 
to  the  soft  palate.  The  invasion  of  the  buccal  cavity  is  characterized 
by  the  formation  of  raised  ulcers  covered  with  granulation  tissue,  the 
surface  of  the  ulcers  being  deeply  fissured.  Lupus  differs  from  other 
forms  of  tuberculous  infection  of  the  mouth  by  the  fact  that  it  is  much 
more  chronic  in  its  course,  and  less  painful. 

When  the  mucous  membrane  of  the  mouth  has  been  infected  with 
tubercle,  either  from  the  sputum  or  from  the  blood,  the  resulting  lesion 
makes  its  appearance  either  as  (i)  vesicles,  or  (2)  a  nodule.  The 
subsequent  developments  of  these  lesions  differ. 

The  vesicles  occur  in  groups,  and,  as  each  vesicle  ruptures,  an 
extremely  superficial  ulcer  is  left. 

The  tuberculous  nodule  in  its  early  stages  resembles  a  gumma  or 
actinomycotic  node.  Later  the  nodule  breaks  down  and  forms  a 
characteristic  ulcer,  with  thin  and  undermined  edges  and  necrotic  base. 
The  nodules  may  be  solitary  or  multiple;  when  multiple  they  generally 
appear  at  the  angle  of  the  mouth  and  soft  palate.  The  ulcers  are  ex- 
tremely painful. 


IQO  REGIONAL    SURGERY 

A  diagnosis  of  tuberculous  lesions  of  the  mouth  may  be  difficult, 
but  will  be  determined  by  (a)  the  presence  (microscopically  ascertained) 
of  tubercle  bacilli  in  the  ulcer,  (b)  a  positive  tuberculin  injection,  or 
(c)  the  presence  of  tuberculous  lesions  in  the  lungs  or  larynx. 

Treatment. — All  tuberculous  manifestations  in  the  mouth  should 
be  freely  excised,  provided  the  condition  of  the  larynx  or  lungs  does  not 
contraindicate  it. 

If  operation  is  not  indicated,  the  ulcer  should  be  treated  by  soothing,  . 
astringent  mouth-washes. 

Actinomycosis  of  the  buccal  cavity  is  usually  associated  with  the 
same  disease  in  the  cheek,  jaw  and  neck. 

The  actinomyces  fungus  is  introduced  through  wounds  of  the  mucous 
membrane  by  the  sharp  points  of  cereal  grains.  The  fungus  is  usually 
deposited  in  the  submucosa,  and  rapidly  proliferates. 

The  cheek  is  not  infrequently  infected,  and  the  mucous  membrane 
soon  becomes  secondarily  involved.  The  first  symptom  is  marked  in- 
duration at  the  site  of  infection.  This  is  followed  by  abscess  formation. 
The  abscess  ruptures  and  discharges  either  into  the  mouth  or  through 
the  skin  by  sinuses,  which  may  tunnel  the  cheek  in  many  directions. 

Sometimes  the  infection  takes  place  in  the  region  of  a  carious  tooth, 
and  a  swelUng  very  Hke  a  gumboil  appears.  The  swelling,  however, 
which  is  of  slower  growth,  breaks  down  and  leaves  a  sinus  discharging 
a  thin  purulent  fluid,  which  usually  contains  the  fungus.  The  sinus 
may  heal  and  break  down  again,  and  a  picture  closely  resembling  a  true 
dental  abscess  is  presented. 

Treatment: — Early  nodes  should  be  excised.  Abscesses  and  sinuses 
should  be  opened  and  curetted,  and  the  soft  tissues  adjoining  the  ab- 
scess or  sinus  removed.  The  resulting  wounds  should  be  well  swabbed 
out  with  iodine,  kept  open,  and  packed  with  iodoform  gauze. 

These  operative  measures  may  have  to  be  repeated  several  times, 
A  successful  issue  is  the  rule*  provided  the  treatment  is  energetic  and 
timely. 

The  local  treatment  may  be  aided  by  the  administration  of  potas- 
sium iodide  in  large  doses,  or  (as  suggested  by  Bevan)  by  the  internal 
administration  of  copper  sulphate  pushed  to  the  limit  of  toleration. 

LEUCOPLAKIA  OF  THE  CHEEK  AND  PALATE 

Leucoplakia  frequently  occurs  on  the  mucous  membrane  of  the 
cheek,  and  less  often  makes  its  appearance  on  the  palate.     On  the  cheek 


DISEASES    OF   THE   BUCCAL   CAVITY  19I 

the  patches  are  more  likely  to  become  horny  than  on  the  tongue  or 
palate,  but  are  not  so  prone  to  ulceration.  In  other  characteristics, 
including  the  hability  to  become  malignant,  the  disease  resembles  that 
affecting  the  tongue. 

The  treatment  should  be  excision. 

TUMORS  OF  THE  BUCCAL  CAVITY 

Epulis  is  a  term  applied  to  any  tumor  on  the  gums,  whether  innocent 
or  malignant.  When  the  clinical  evidence  does  not  sufficiently  indi- 
cate its  exact  nature,  a  section  of  th^  growth  should  be  submitted  to  a 
microscopic  examination. 

Innocent  Tumors. — Angiomata,  Lymphangiomata,  Lipomata,  Fi- 
bromata, Papillomata,  Adenomata. 

Malignant  Tumors. — Endotheliomata,  Carcinomata,  Sarcomata. 

Cysts. — Mucous  Cysts,  Dermoids. 

Any  of  these  tumors  may  appear  in  the  buccal  cavity. 

TUMORS 

An  Angioma  may  appear,  either  as  a  simple  or  as  a  cavernous 
n£evus,  on  the  buccal  mucous  membrane.  The  cavernous  naevus 
shows  a  marked  tendency  to  increase  in  size,  and  the  lip  and  cheeks 
may  become  replaced  by  a  soft  tumor  with  bluish  knob-like  projec- 
tions on  the  mucous  surface. 

Treatment. — If  small  a  naevus  may  be  removed,  the  incisions  going 
into  healthy  tissue  outside  the  limits  of  the  enlarged  vessels.  If  very 
large  these  tumors  are  best  left  alone;  repeated  hemorrhage  is,  how- 
ever, an  indication  for  operation.  Careful  preliminary  control  of  the 
hemorrhage  is  essential.  If  operation  be  out  of  the  question,  and 
repeated  hemorrhage  occurs,  then  the  injection  of  absolute  alcohol 
deeply  into  the  tumor  may  be  tried. 

Lymphangiomata  and  lipomata  are  found  in  the  tongue,  but  rarely 
make  their  appearance  elsewhere  in  the  buccal  cavity. 

Fibromata  are  somewhat  more  common,  are  usually  pedunculated, 
and  grow  from  the  gums  and  inner  side  of  the  cheek. 

Adenomata  are  very  rarely  seen  in  the  mouth;  when  they  do  occur, 
the  palate  is  the  site  usually  chosen. 

Papillomata  are  not  uncommon.  They  occur  frequently  in  con- 
nection with  leucoplakia  of  the  cheek,  and  present  the  appearance  more 


192  REGIONAL   SURGERY 

of  a  papillomatous  thickening  of  the  epithelium  then  of  definite  tumors. 
This  condition  should  always  be  regarded  with  grave  suspicion,  as 
sooner  or  later  a  change  to  a  definite  epithehoma  takes  place.  The 
early  removal  of  such  a  papillomatous  patch  is  always  urgently  necessary. 

MALIGNANT  TUMORS 

1.  Endotheliomata  or  mixed  tumors  may  occur  anywhere  in  the 
buccal  cavity,  but  their  favorite  site  is  the  soft  palate.  Just  as  in 
the  parotid,  their  growth  in  the  early  stages  is  slow,  causing  slight  in- 
convenience. Then,  suddenly,  their  latent  energy  finds  vent;  the 
tumor  grows  actively,  and  presents  all  the  features  of  malignancy. 
Wide  removal  is,  of  course,  the  treatment  indicated. 

2.  Sarcomata  occurring  in  the  buccal  cavity  are  usually  connected 
with  the  periosteum  of  the  jaws  and  hard  palate,  and  will  be  described 
under  that  section. 

3.  Carcinomata  may  occur  anywhere  on  the  mucous  membrane 
of  the  mouth,  the  cheek,  the  floor  of  the  mouth  and  the  hard  palate 
being  the  sites  most  commonly  affected.  The  majority  of  cases  occur 
on  the  cheek,  as  an  extension  of  growth  from  a  lip  carcinoma.  When 
the  growth  originates  in  the  buccal  cavity  itself,  it  is  generally  in 
connection  with  mechanical  or  dental  irritation.  On  the  cheek  epithe- 
lioma is  frequently  associated  with  leucoplakia  and  papillomatous 
thickening  of  the  epithelium;  the  mucous  membrane  opposite  the  last 
molar  tooth  is  the  most  common  situation. 

The  floor  of  the  mouth  adjoining  the  frsenum  is  not  an  uncommon 
situation;  occasionally  the  floor  of  the  mouth  is  invaded  by  a  cyUndrical- 
celled  carcinoma,  which  originates  in  the  sublingual  gland. 

The  most  uncommon  variety,  however,  is  an  epithehoma  which 
appears  as  a  hard,  flat  ulcer,  and  as  it  grows  extends  to  the  tongue  and 
lower  jaw. 

The  oral  surfaces  of  the  jaws  and  hard  palate  are  affected  by  two 
cUnical  types  of  epithehoma:  (i)  The  hard  ulcerating  type.  (2)  The 
soft  type. 

The  Hard  Ulcerating  Type. — In  this  variety  the  induration  is  very 
evident.  It  surrounds  an  ulcer,  which  grows  slowly  and  tends  to 
extend  superficially  rather  than  invade  the  bone. 

The  soft  variety  is  more  mahgnant,  grows  more  rapidly,  bleeds 
easily,  does  not  ulcerate  so  early,  and  tends  to  invade  the  bone  and 
extend  into  the  antrum. 


DISEASES    OF   THE  BUCCAL   CAVITY  I93 

Treatment. — The  ideal  operation  should  be  adhered  to,  viz.,  wide 
local  excision,  together  with  that  of  the  glandular  area  draining  the  part 
affected. 

We  have  to  consider  the  treatment  of  {a)  carcinoma  of  the  cheek, 
which  frequently  extends  on  the  side  of  the  lower  jaw;  {h)  carcinoma 
of  the  floor  of  the  mouth;  (c)  carcinoma  of  the  palate  or  alveolar  border 
of  upper  jaw. 

Treatment  of  carcinoma  of  the  cheek,  which  also  involves  the  lower 
jaw. 

1.  Make  incisions  DCE,  CB,  BA,  BG  and  CF  (Fig.  105).     Reflect 
the  flaps. 

2.  Divide  sterno-mastoid  at  omohyoid  level.     Clear  out  anterior, 
posterior  and  digastric  triangles  as  far  as  the  submaxillary  gland. 


Fig.   105.  Fig.  106. 

3.  From  before  backward,  dissect  out  the  tissues  containing  the 
submental  glands,  as  far  as  the  submaxillary  gland. 

4.  Divide  upper  end  of  sterno-mastoid,  and  from  behind  forward 
remove  all  tissue  containing  the  lower  glands  of  the  parotid  group, 
and  the  upper  internal  jugular  chain.  Tie  the  external  carotid, 
perform  laryngotomy  and  plug  the  larynx.  Divide  the  jaw  in 
front  of  and  behind  the  growth,  opening  the  buccal  cavity. 

5.  Complete  the  incision  BH;  pull  down  the  growth  and  infected 
portion  of  the  jaw,  and  complete  the  dissection  of  the  digastric 
triangle  from  above  downward. 

6.  Sew  up  flaps  as  in  Fig.  106,  stitching  the  mucous  membrane  of 
the  floor  of  the  mouth  to  the  side  of  the  flaps,  so  as  to  fill  in  the 
areas  removed  from  the  cheek.  The  area  left  is  plugged  with 
iodoform  gauze. 

In  very  extensive  cases  a  temporary  clamping  of  the  common  carotid 
facilitates  the  operation. 
13 


194 


REGIONAL   SURGERY 


In  this  operation  the  growth  and  its  glandular  draining  areas  are 
removed  in  continuity. 

CARCINOMA  OF  ALVEOLAR  BORDER  OF  UPPER  JAW  AND 

HARD  PALATE 

I.  Clamp  both  common  carotids   as   advised  by   Crile,   perform 
laryngotomy  and  plug  the  larynx. 


Fig.  107. 


Fig.  108. 


Turn  back  flaps,  and  pull  up  the 


Make  incisions  as  in  Fig.  107. 

nose. 

Divide  with  a  chisel  alveolar  border  of  jaw  as  in  Fig.  108,  and 

complete  the  removal  of  the  hard  palate  with  cutting  forceps. 

Plug  the  cavity  with  iodoform  gauze. 

If  the  growth  be  more  laterally  placed, 
incisions  ABCD  and  EF  may  be  placed 
as  in  Fig.  109.  Otherwise  the  steps  of  the 
operation  are  similar. 

The  main  essentials  of  operations  in- 
volving removal  of  portions  of  upper  jaw 
and  palate  are:  (i)  absolute  control  of 
bleeding  by  use  of  Crile's  clamps;  (2)  easy 
administration  of  the  anaesthetic,  and  pre- 
vention of  inspiration  of  blood  down  the 
trachea,  by  a  preliminary  laryngotomy. 
Two  or  three  weeks  later  the  dissec- 
tion of  one  or  both  sides  of  the  neck,  according  to  the  nature  of  the 
case,  is  performed  in  the  manner  I  have  recommended  in  lingual  cancer. 

CARCINOMA  OF  FLOOR  OF  THE  MOUTH  INVOLVING 

LOWER  JAW 

I.  Incision  ABDEFis  made,  and  flaps  turned  upward  and  downward 
(Fig.  no). 


Fig.  109. 


DISEASES    OF    THE  BUCCAL   CAVITY  1 95 

2.  Dissection  of  this  side  of  neck  is  performed  as  has  been  advised 
for  removing  glandular  draining  areas;  it  is  proceeded  with  up 
to  the  jaw. 

3.  Incision  BC  is  then  made,  and  digastric  triangle  on  that  side 
dissected  up  as  far  as  the  jaw. 

4.  Clamp  the  common  carotid  on  the  first  side  dissected,  tie  the 
external  carotid  on  the  other  side,  and  per- 
form laryngotomy,  plugging  the  larynx. 

5.  Divide  the  required  amount  of  lower  jaw 
with  a  Gigli's  saw;  widely  remove  the  growth 
and  complete  the  dissection  of  digastric 
triangle  from  above  downward. 

6.  Close  the  buccal  cavity  as  far  as  possible  by 
stitching  the  tongue  to  the  flaps. 

7.  Two  or  three  weeks  later  make  a  complete  Fig.  ho. 
dissection  of  the  neck  on  the  side  on  which 

the  digastric  triangle  only  had  been  done. 
If  the  floor  of  the  mouth  only  is  involved,  the  operation  is  similar 
to  that  performed  for  removal  of  the  tongue. 

CYSTS  OF  THE  MUCOUS  GLANDS 

Retention  cysts  of  the  mucous  glands  are  usually  situated  on  the 
inner  surface  of  the  Ups  and  cheeks;  their  peculiar  bluish  appearance  is 
distinctive.  They  are  removed  by  shelling  them  out,  by  incision,  or 
by  destruction  with  the  cautery. 

INJURIES  OF  THE  BUCCAL  CAVITY 

Wounds. — During  the  act  of  eating,  slight  wounds  may  be  inflicted 
by  pieces  of  bone,  etc.  These  sHght  accidental  injuries  are  usually  of 
little  importance.  More  severe  penetrating  wounds  of  the  cheeks,  soft 
palate  and  floor  of  the  mouth  are  seen  in  children  who  have  fallen  while 
holding  some  pointed  object  in  the  mouth. 

Laceration  of  the  mucous  membrane  covering  the  gums  is  associated 
with  tooth-extraction,  and  less  frequently  with  fracture  of  the  jaw. 
The  most  extensive  lacerations  are  caused  by  bullets  and  other  pro- 
jectiles. 

Although  the  enormous  number  of  microorganisms  inhabiting  the 
oral  mucous  membrane  cause  infection  only  in  exceptional  cases,  severe 


196  REGIONAL    SURGERY 

and  even  fatal  sepsis  may  occasionally  occur,  especially  in  wounds  com- 
plicated with  injury  to  the  bones.  Although  the  risk  from  tooth- 
extraction  is  usually  very  sh'ght,  yet  a  point  of  entrance  is  afforded  to 
organisms  and  necrosis  of  the  jaw  may  be  the  consequence. 

Treatment. — The  daily  cleansing  of  the  teeth  and  mouth  is  of  very 
great  prophylactic  value  in  wounds  of  the  buccal  cavity.  The  brushing 
of   the  teeth  is  of  the  first  importance. 

As  a  rule,  wounds  are  best  left  open  to  ensure  adequate  drainage. 

The  use  of  mild  antiseptic  mouth- washes  is  advisable.  No  strong 
solutions  should  be  used;  they  are  apt  to  inflame  the  mucous  membrane, 
and  this  condition  always  increases  the  virulence  of  resident  bacteria. 

Bums  and  Scalds. — Burns  and  scalds  of  the  buccal  mucous  mem- 
brane usually  result  from  contact  with  steam  or  hot  fluids. 

During  severe  boiler  explosions  steam  may  be  forced  into  the  nose, 
mouth  and  pharynx,  and  may  cause  severe  scalding  of  the  mucous 
membrane. 

Burns  of  this  region  not  infrequently  arise  from  children  attempting 
to  drink  from  the  spout  of  a  tea  kettle. 

The  swallowing  of  corrosive  poisons,  concentrated  acids  and  alkalis 
produces  severe  burns. 

In  mild  cases  of  burns  and  scalds  the  epithelium  turns  a  grayish- 
white  color,  and  is  soon  cast  off.  In  severe  cases  extensive  swelling 
and  oedema,  followed  by  sloughing,  may  result. 

Treatment. — Bland  mouth-washes,  and  gruel  as  an  article  of  diet. 


SECTION  XI 
INJURIES  AND  DISEASES  OF  THE  TONGUE 

By 
SIR  H.  L.  MAITLAND,  M.  Ch.,  M.  B. 

Injuries  to  the  tongue  include: 

1.  Wounds. 

2.  Bums  and  scalds. 

3.  Stings  of  insects. 

WOUNDS   OF  THE  TONGUE 

A  wound  of  the  tongue  may  be  produced  by  various  objects  and  in 
various  ways,  e.g.,  by  a  fall  or  a  blow  when  some  foreign  substance, 
such  as  a  lead  pencil  or  a  pipe-stem  is  in  the  mouth,  from  a  bayonet 
stab  or  bullet  wound;  but  by  far  the  most  frequent  wounds  of  the 
tongue  are  those  made  by  the  teeth.  "Biting  the  tongue"  is  the  con- 
sequence either  of  a  fall  or  of  a  blow  on  the  chin  when  the  tongue 
happens  to  be  protruded;  the  most  serious  bites  occur  either  in  epileptic 
or  apoplectic  patients. 

It  must  be  always  borne  in  mind  that  a  wound  of  the  tongue  may 
be  complicated  by  the  presence  of  a  foreign  body;  and  in  treatment 
the  main  indication,  after  attending  to  the  thorough  control  of  hemor- 
rhage, is  to  assure  ourselves  that  no  foreign  substance  remains  inbedded 
in  the  musculature  of  the  organ;  for  this  is  the  most  frequent  cause  of 
secondary  hemorrhage. 

The  great  dangers  that  accompany  wounds  of  the  tongue,  arranged 
in  sequence  of  time,  are: 

(a)  Primary  hemorrhage. 

(b)  Sepsis. 

(c)  Secondary  hemorrhage,  and  occasionally 

(d)  CEdema  of  the  glottis. 

(A)  Primary  Hemorrhage. — The  bleeding  vessel  is  either  near  the 
tip  or  far  back.  If  the  first,  its  control  is  an  easy  proceeding;  if  the 
second,  it  is  quite  otherwise.  A  gag  must  be  inserted  and  the  wound 
temporarily  plugged  while  arrangements  are  being  made  to  stop  the 

197 


1 98  REGIONAL    SURGERY 

bleeding  permanently;  or  we  may  avail  ourselves  of  Heath's  manoeuvre 
— passing  the  forefinger  to  the  back  of  the  tongue  and  hooking  the 
whole  organ  forward,  together  with  the  hyoid  bone,  thus  putting  the  lin- 
gual arteries  on  the  stretch.  Opening  the  jaws  widely  by  means  of 
the  gag,  we  administer  an  ansesthetic  and  expose  the  wound;  when  the 
bleeding  vessel  is  visible,  we  ligate  it;  if  it  is  not  visible,  it  is  better  to 
enlarge  the  wound  slightly  till  the  vessel  comes  into  view  and  can  be 
secured.  If,  however,  the  hemorrhage  is  venous,  or  the  result  of  general 
oozing,  bringing  the  edges  of  the  wound  together  by  deep  sutures  will 
probably  suffice. 

(B)  Sepsis. — All  stitches  must  be  removed,  incisions  may  be 
required,  and  the  condition  treated  on  general  principles. 

(C)  Secondary  Hemorrhage. — This  may  require  preliminary 
laryngotomy  and  plugging  of  the  pharynx.  Owing  to  the  sloughy  con- 
dition of  the  tissues,  Hgation  of  the  bleeding  vessel  may  be  a  matter  of 
extreme  difficulty.  It  is  then  better  to  under-run  the  vessel  with  a  silk 
ligature  by  means  of  a  curved  needle.  If  this  measure  be  not  suc- 
cessful, it  may  be  necessary  to  tie  the  lingual  artery  beneath  the  chin. 
Having  arrested  the  hemorrhage  make  diHgent  search  for  a  foreign  body, 
the  most  frequent  cause  of  this  complication. 

(D)  (Edema  of  the  glottis  may  necessitate  tracheotomy. 

The  after-treatment  of  wounds  of  the  tongue  is  of  importance. 
Oral  asepsis  must  be  promoted  by  the  frequent  use  of  mild  antiseptic 
mouth-washes  (carbolic  acid  i  in  80,  peroxide  of  hydrogen  i  in  4, 
sanitas,  etc.). 

A  fluid  diet  for  a  time  is  usually  necessary. 

Foreign  Bodies  in  the  Tongue. — If  a  wound  does  not  heal  readily, 
or  leaves  an  ulcer,  the  presence  of  a  foreign  body  may  be  suspected. 
Occasionally  the  wound  may  heal  over  leaving  a  foreign  substance — 
such  as  a  tooth,  a  piece  6i  pipe-stem,  a  bullet,  or  a  needle — embedded 
in  the  tongue.  If  this  occurs  a  hard,  indolent  and  circumscribed  swell- 
ing subsequently  develops,  which  may  be  mistaken  for  a  growth. 
The  cause  of  such  a  sweUing  is  easily  overlooked  if  it  be  due  to  a  bristle 
from  a  toothbrush  or  to  a  needle. 

BURNS  AND  SCALDS 

Burns  and  scalds  of  the  tongue  vary  from  trivial  abrasions  to 
profound  destructive  lesions.  Slight  burns  arise  from  a  lighted  cigar 
or  cigarette  accidentally  touching  the  tongue.  The  epithelium  may  be 
simply  denuded,  or  ulceration  may  take  place;  and  in  a  person  past  the 


INJURIES   AND   DISEASES   OF   THE   TONGUE  1 99 

meridian  of  life  the  ulceration  may  become  malignant.  The  severer 
form  of  burns  are  usually  caused  by  mineral  acids  taken  with  suicidal 
intent. 

Scalds  of  the  tongue  are  by  no  means  uncommon.  They  are  more 
frequently  met  with  in  young  children,  from  attempting  to  drink  out 
of  the  spout  of  a  kettle  of  boiling  water. 

Ice  to  the  neck,  liquid  food,  and  bland  moiith- washes  are  the  lines 
of  treatment  indicated. 

Stings  from  insects  are  so  rare  that  the  subject  requires  but  brief 
attention.  Wasps  and  bees  accidentally  introduced  into  the  mouth  on 
articles  of  food  may  injure  the  tongue.  Considerable  swelling  is  the 
marked  symptom. 

Inflammatory  Affections  of  the  Tongue. — As  Jong  as  the  mucous 
membrane  of  the  tongue  remains  intact,  the  extremely  numerous  patho- 
genic germs  resident  in  the  mouth  do  no  harm.  But  as  soon  as  the  soil 
is  rendered  more  susceptible  by  injury,  and  the  tissue-resistance  is 
lowered,  there  is  an  increase  in  germ  activity,  which  results  in  various 
inflammatory  changes. 

The  classification  suggestion  by  John  Flynn  may  be  taken  as  a  poor 
working  one. 

Acute  Conditions. 

1.  Acute  superficial  glossitis. 

2.  Suppuration  of  the  tongue: 

(a)  Local  abscess. 

(b)  Parenchymatous  glossitis. 

3.  Lingual  quinsy. 

4.  Gangrene  of  the  tongue. 

Chronic  Conditions. 

1.  Leucoplakia  (chronic  superficial  glossitis). 

2.  Ulcers: 

(A)  Non-specific  (i)  simple, 

(2)  traumatic, 

(B)  Specific  (3)  tuberculous, 

(4)  s)TDhilitic, 

(5)  actinomycotic. 

Acute  Superficial  Glossitis. — Acute  superficial  glossitis  may  be 
either  local  or  diffuse.  The  local  variety  follows  most  slight  injuries 
or  burns,  and  is  usually  of  trivial  importance.  Applications  of  borax 
rarely  fail  to  effect  a  cure.    The  diffuse  form  is  usually  only  a  part  of 


200  REGIONAL   SURGERY 

general  stomatitis,  such  as  formerly  followed  the  use  of  mercury.  Oc- 
casionally, however,  we  meet  with  a  condition  of  the  tongue  character- 
ized by  an  herpetic  eruption;  it  is  of  nervous  origin,  and  is  probably 
closely  allied  to  herpes  zoster.  In  rare  cases  the  tongue  is  invaded  by 
diphtheria;  the  membrane  then  appears  at  the  root,  and  is  directly 
continuous  with  that  on  the  fauces.  A  membranous  glossitis  is  also 
met  with  in  children  suffering  from  measles.  A  mild  form  of  acute 
superficial  glossitis  (thrush)  is  due  to  a  growth  of  the  oidium  albicans. 
These  three  forms  of  the  disease,  however,  belong  to  the  domain  of  the 
physician. 

Treatment  of  Acute  Superficial  Glossitis. — All  superficial  inflam- 
matory conditions  of  the  tongue  improve  on  the  application  of  bland 
mouth-washes,  such  as  chlorate  of  potash.  This  drug  is  also  of  value 
taken  internally. 

Suppuration  of  the  Tongue. — Acute  suppuration  occurs  in  the 
tongue,  as  in  other  tissue,  under  two  forms:  the  localized,  and  the  dif- 
fuse. It  has  been  customary  to  describe  these  two  conditions  sepa- 
rately under  the  headings,  abscess  of  the  tongue  and  acute  parenchy- 
matous glossitis.  In  accordance  with  the  teachings  of  bacteriology  we 
prefer  to  discuss  them  under  a  common  heading.  Both  conditions  are 
due  to  pyogenic  organisms ;  the  circumscribed  abscess  is  more  especially 
caused  by  the  staphylococcus  pyogenes  aureus  and  by  other  less  viru- 
lent organisms,  the  so-called  parenchymatous  glossitis  (or  rather  diffuse 
cellulitis)  by  the  streptococcus  pyogenes. 

These  organisms  reach  the  tongue  either  directly  through  a  wound — 
especially  when  a  foreign  body  remains  undiscovered  in  the  lingual  sub- 
stance— or  indirectly  through  the  lymphatic  vessels  from  carious  teeth, 
or  from  the  condition  of  pyorrhea  alveolaris. 

Acute  abscess  in  the  tongue  is  characterized  by  a  tender  localized 
swelHng  in  the  organ,  of  gradual  onset  with  pain  referred  to  the  ear,  and 
only  rarely  giving  the  physical  signs  of  fluctuation.  Diffuse  cellulitis, 
on  the  other  hand,  spreads  with  great  rapidity,  the  organ  sometimes 
swelling  to  thrice  its  normal  size  in  the  course  of  a  few  hours.  It  now 
protrudes  from  the  oral  cavity,  and  is  both  painful  and  stiff.  In  a  viru- 
lent infection  the  swelUng  may  be  so  great  as  to  make  tracheotomy 
necessary  to  prevent  asphyxia.  There  is  always  profuse  salivation  and 
great  impairment  of  speech  and  deglutition;  oedema  of  the  glottis  and 
septic  pneumonia  may  supervene. 

The  treatment  of  either  variety  of  suppuration  of  the  tongue  is  the 
same  as  in  other  regions — free  incision.     Having  previously  passed  a 


INJURIES   AND   DISEASES   OF  THE   TONGUE  20I 

piece  of  silk  through  the  forepart  of  the  tongue  to  steady  it,  make  the 
cut  in  the  dorsal  surface,  guiding  the  bistoury  with  the  left  index-finger 
to  the  tender  spot.  In  the  case  of  acute  abscess,  cut  longitudinally 
and  as  deep  as  may  be  necessary  to  open  the  abscess.  If  the  abscess  is 
practically  subHngual  (that  is,  occupying  the  floor  of  the  mouth)  it 
should  of  course  be  opened  from  beneath,  taking  care  of  the  ranine 
vessels;  but  it  is  generally  better  to  incise  the  upper  aspect  of  the  tongue, 
since  there  is  little  fear  of  hemorrhage  there. 

In  diffuse  cellulitis  multiple  scarification  is  demanded;  better  still 
is  a  longitudinal  incision  on  each  side  of  the  raphe,  midway  between  it 
arid  the  margin  of  the  tongue,  and  cutting  deeply  into  the  muscular 
substance.  There  is  marked  and  rapid  relief  from  this  apparently 
heroic  treatment. 

Chronic  suppuration  is  rare,  yet  its  possibility  should  be  borne 
in  mind  when  there  exists  in  the  substance  of  the  tongue  a  small,  cir- 
cumscribed, smooth  tumor  of  slow  development,  without  any  well- 
marked  pain  or  tenderness.  An  incision  clears  up  the  doubt,  and  cures 
the  disease.  A  very  fatal  but  uncommon  form  of  this  disease  may  be 
due  to  anthrax. 

Inflammation  of  the  Lingual  Tonsil  (Lingual  Quinsy) . — The  condi- 
tion known  as  lingual  quinsy  arises  from  an  infection  of  the  mass  of 
lymphoid  folHcle  situated  at  the  base  of  the  tongue.  In  some  cases  it 
is  an  extension  of  inflammation  of  the  faucial  tonsil  to  the  base  of  the 
tongue  and  the  surrounding  parts;  in  others  the  affection  is  limited  to 
the  lingual  tonsil.  There  is  tenderness  at  the  hinder  part  of  the 
tongue,  together  with  symptoms  of  pressure  at  the  tongue-base,  such 
as  dyspnoea  and  dysphagia. 

In  severe  cases  the  treatment  is  incision. 

Gangrene  of  the  tongue  is  not  often  seen.  It  may  arise  from  acute 
phagedena  in  smallpox,  and  sj^^hilis,  or  from  severe  parenchymatous 
glossitis.  Extension  of  noma  from  the  cheek,  and  anthrax  of  the  tongue, 
may  also  be  responsible  for  it. 

Treatment. — Attention  to  the  general  health;  antisj-philitic  treat- 
ment, if  a  syphiUtic  origin  is  indicated;  nutrient  enemata,  if  the  patient 
be  unable  to  take  food;  and  frequent  lavage  of  the  mouth  with  mild 
antiseptics,  are  the  proper  lines  of  treatment. 

Leucoplakia. — ^Leucoplakia  is  regarded  by  many  authorities  as 
essentially  a  chronic  superficial  inflammation;  but  it  is  questionable 
whether  it  should  not  rather  be  regarded  as  a  degeneration  indicating 
tissue-senescence. 


202  REGIONAL   SURGERY 

The  outstanding  feature  of  this  disease  is  keratosis;  there  is  an 
overgrowth  of  the  epithehal  layers,  with  a  disappearance  of  the  normal 
papillae. 

This  cornification  forms  smooth,  white  patches  on  the  surface  of 
the  tongue.  The  patches  may  develop  and  extend  as  far  back  as 
the  circumvallate  papillae.  The  favorite  site  of  the  disease  is  the 
anterior  half  of  the  upper  surface  of  the  tongue.  The  edges  and 
under-surfaces  are  not  so  often  affected.  It  may  appear  first  as  a  red 
patch  devoid  of  papillae;  this  patch  then  becomes  covered  with  layers 
of  thickened  squamous  epithelium,  which  form  a  yellowish  white 
crust. 

The  disease  may  also  appear  as  a  small  bluish  white  patch,  as  if 
the  surface  of  the  mucous  membrane  had  been  brushed  with  a  dilute 
solution  of  silver  nitrate.  This  white  plaque  may  slowly  spread  over 
the  tongue,  portions  of  it  becoming  thickened  and  cornified.  At  first 
the  patches  are  smooth,  but  later  become  fissured,  the  fissures  sometimes 
ulcerating.  Or  a  benign  warty  growth  may  make  its  appearance.  The 
importance  of  this  disease  lies  in  the  fact  that  it  is  a  precancerous  con- 
dition. It  is  very  chronic,  and  may  take  years  to  progress.  But  the 
transition  of  the  ulcerating  fissure  and  warty  growth  into  an  epitheHoma 
is  unfortunately  anything  but  a  rare  occurrence. 

Etiology. — Syphilis  is  undoubtedly  a  predisposing  cause  of  impor- 
tance. 

It  seldom  occurs  in  the  young,  and  does  not  often  commence  in 
persons  over  60  years  of  age.  Rarely  is  it  seen  in  women.  Smoking, 
alcohol  and  irritation  from  carious  teeth  are  contributing  causes  of 
the  disease. 

The  most  marked  examples  of  the  disease  are  seen  in  the  sj^hilitic 
whose  tongue  is  subjected  to  constant  irritation  from  alcohol  and 
tobacco. 

Smokers'  patch  is  an  early  form  of  leucoplakia.  It  appears  on  the 
tongue  where  the  pipe-stem  habitually  rests  on  it,  and  where  the  smoke 
stiikes  it.     It  makes  its  appearance  in  two  forms: 

1.  As  a  pearly,  bluish  white  patch,  perfectly  smooth;  or 

2.  As  a  red,  smooth  patch  sHghtly  depressed  below  the  surface, 
which  later  becomes  covered  with  whitish,  yellow  epithelium. 
It  may  disappear  when  the  source  of  irritation  is  removed,  or  it 
may  go  on  and  spread. 

Symptoms. — In  the  early  stages  the  disease  causes  but  few  symp- 
toms.    In  later  stages  the  patient  may  complain  that  the  tongue  is 


INJURIES   AND   DISEASES    OF   THE    TONGUE  203 

hard  and  dry;  as  the  patches  extend  and  become  fissured,  the  tongue 
may  become  painful  and  extremely  sensitive,  and  eating,  drinking 
and  speaking  may  be  interfered  with.  Some  tongues  in  this  condition 
are  subject  to  recurrent  attacks  of  acute  inflammation,  with  the  accom- 
panying symptoms. 

Treatment. — i.  Prophylactic. — Since  this  is  a  precancerous  condi- 
tion, treatment  should  be  begun  as  soon  as  a  diagnosis  is  made,  and  all 
sources  of  irritation  to  the  tongue  should  be  removed.  Stumps  and 
carious  teeth  should  be  extracted,  ill-fitting  tooth-plates  rectified,  smok- 
ing and  chewing  prohibited,  alcohol  taken  only  in  a  very  diluted  form. 
Digestion  should  be  attended  to,  and  all  articles  which  cause  the 
tongue  to  smart  should  be  eliminated  from  the  diet. 

2.  Local  Treatment. — ^Local  appHcations  do  not  give  any  permanent 
benefit.  The  patches  should  be  removed  with  the  knife.  This  form 
of  treatment  is  especially  indicated  when  the  disease  is  localized,  or  if  it 
be  associated  with  chronic  ulceration.  Caustics  should  never  be  used. 
Mild  appHcations,  such  as  glycerine  and  borax,  give  some  relief.  Buthn 
recommends  the  application  of  ointments  applied  to  the  tongue  after 
it  has  been  dried.  He  uses  an  ointment  the  basis  of  which  is  cold  cream, 
or  two  parts  of  vasehne  with  six  of  lanoUne.  With  this  basis  he  combines 
various  drugs,  such  as  cocaine,  borax,  morphine,  etc.  To  individuals 
who  sleep  with  the  mouths  open,  and  who  suffer  from  a  dry  tongue,  this 
treatment  gives  relief. 

ULCERATION  OF  THE  TONGUE 

From  a  chnical  standpoint  ulcers  of  the  tongue  are: 
(a)  Evidently  simple. 
{h)  Plainly  malignant, 
(c)  Doubtful. 

In  the  last  case  the  doubt  should  always  be  solved  by  excising  a 
piece  of  the  ulcer  and  submitting  it  to  microscopic  examination. 

Further,  here  as  elsewhere  there  are  two  great  classes  of  ulcers: 

1.  Chronic  non-infective  ulcers  {i.e.,  not  due  to  any  specific  organ- 
isms). 

2.  Chronic  infective  ulcers — those  that  are  due  to  the  agency  of 
a  specific  organism,  such  as  the  spirochaeta  palKda  and  the  tubercle 
bacillus. 

Chronic  Non-infective  Ulcers. — {a)  Simple  Ulcers. — These  usually 
supervene  on  the  different  manifestations  of  chronic  superficial  glossitis. 


204  REGIONAL   SURGERY 

It  is  not  difficult  to  understand  why  these  conditions  are  favorable  to 
ulceration,  since  in  them  the  epithelium  covering  the  tongue  is  de- 
generate, unstable  and  poorly  nourished. 

Although  ill  many  tongues  subject  to  chronic  superficial  glossitis 
there  is  an  increase  in  quantity  of  the  covering  epitheHal  cells,  still  there 
is  a  deterioration  in  quality,  and  the  epitheKum  is  easily  shed,  leaving 
raw  and  unprotected  areas  that  should  be  shielded  from  irritants,  a 
condition  of  affairs  which  favors  the  transition  of  the  simple  into  the 
malignant  ulcer. 

These  ulcers  are  generally  found  close  to  the  middle  line  in  the  an- 
terior portion  of  the  tongue. 

Traumatic  ulcer  is  the  form  which  arises  from  the  continued  action 
of  some  exciting  cause,  e.g.,  ill-fitting  tooth-plates  or  rough  carious  teeth 
(dental  ulcer).  The  situation  of  the  ulcer  is  usually  on  the  lateral 
borders,  corresponding  in  situation  to  that  of  the  irritating  agent. 
It  begins  as  an  abrasion.  If  the  source  of  irritation  be  removed  at  this 
stage,  the  abrasion  heals;  if  it  is  not  removed,  it  becomes  a  definite 
ulcer.  If  the  irritation  be  continued,  the  edges  become  elevated  and 
indurated,  characteristics  of  sinister  significance;  the  character  of  the 
ulcer  has  now  become  doubtful — it  has  possibly  become  malignant. 

Herpetic  ulcer  may  accompany  an  exanthem,  or  may  be  idiopathic. 
It  makes  its  appearance  as  a  vesicle  which  ruptures,  leaving  an  oval, 
sensitive  ulcer.     They  are  usually  multiple  and  appear  in  crops. 

Treatment. — The  essential  treatment  of  simple  ulcers  consists  in  the 
early  and  complete  removal  of  the  cause.  Remove  ill-fitting  plates, 
file  or  remove  rough  and  carious  teeth.  Use  frequently  non-irritating 
mouth-washes,  such  as  glycerine  and  borax,  or  saturated  solution  of 
potassium  chlorate;  or  frequently  paint  the  ulcer  with  a  solution  of 
chromic  acid,  lo  grains  to  the  ounce  of  water. 

To  a  painful  ulcer  apply  a  soothing  application;  to  ulcers  less 
sensitive  apply  astringents. 

An  important  rule  to  follow  is:  Excise  a  simple  chronic  ulcer, 
which  does  not  rapidly  yield  to  treatment. 

Chronic  infective  ulcers  will  be  dealt  with  under  the  headings, 
Tubercle,  Syphilis,  and  Actinomycosis  of  the  tongue. 

TUBERCULOUS  DISEASE  OF  THE  TONGUE 

Although  a  rare  disease,  it  may  arise  in  various  ways: 
I.  As  lupus  of  the  tongue,  by  extension  from  the  face  or  by  contagion 
from  the  hp. 


INJURIES    AND   DISEASES    OF   THE    TONGUE  20$ 

2.  As  secondary  to  pulmonary  or  laryngeal  tubercle,  from  infection 
carried  by  the  sputum. 

3.  As  h£emic  infection  from  tubercle  elsewhere. 

4.  As  a  primary  lesion  (this  is  extremely  rare). 
Tuberculous  lesions  take  the  following  forms: 

1.  The  nodule, 

2.  The  ulcer. 

3.  The  fissure. 

The  first  sign  of  the  disease  may  be  the  appearance  of  several 
small  nodules  on  the  upper  surface  of  the  tongue.  These  do  not  attain 
any  larger  size,  but  caseate,  break  down  and  form  aw  ulcer  with  uneven 
base,  with  pale  and  flabby  granulation  showing  through  a  viscid  yel- 
lowish gray  discharge.  The  edges  are  red,  sharp-cut  and  indurated. 
Around  the  ulcer  there  may  be  minute  yellowish  elevations,  which  are 
additional  tuberculous  foci.  The  ulcer  may  progress  and  destroy  the 
deeper  parts  of  the  organ,  and  may  lead  to  the  complete  destruction 
of  the  tip  of  the  tongue.  The  organ  in  this  condition  becomes  very 
painful,  the  submaxillary  glands  become  enlarged,  and  there  is  very 
great  discomfort  from  salivation.  In  place  of  frank  ulceration  the 
nodule  may  break  and  leave  a  fissure,  which  is  usually  very  deep  com- 
pared with  the  extent  of  its  surface.  The  sides  of  the  fissure  may  be 
raised  into  folds,  to  which  the  name  "tuberculous  papilloma"  has 
been  applied. 

Treatment. — When  the  ulcer  is  single  and  small,  and  there  is  no 
evidence  of  tuberculous  disease  elsewhere,  excision  of  the  diseased 
portion  of  the  tongue  is  indicated.  This  radical  method  of  treatment 
is  especially  indicated  in  ulcers  limited  to  the  tip  of  the  tongue,  which 
cause  great  pain  on  mastication  and  articulation.  If  there  be  coexistent 
disease  in  the  lung  or  larynx,  each  case  has  to  be  decided  on  its  merits, 
always  remembering  that  cut  surfaces  are  liable  to  be  re-infected.  All 
cut  surfaces  should  be  accurately  stitched.  When  excision  is  imprac- 
ticable, palHative  measures  have  to  be  adopted.  Under  local  anaes- 
thesia, curette  the  ulcer;  apply  pure  carbolic  followed  by  alcohol,  then 
dust  the  surface  with  orthoform.  This  palliative  operation  may  be 
repeated  till  healthy  granulation  appears.  Stringent  mouth- washes, 
such  as  alum  or  tannin,  are  used  if  healing  is  delayed. 

If  the  ulcer  be  too  extensive  to  deal  with  in  this  way,  it  may  be 
painted  with  a  20  per  cent,  solution  of  lactic  acid  every  second  day. 
Orthoform  is  frequently  dusted  on  it.  If  this  does  not  give  relief,  the 
surface  of  the  ulcer  should  be  frequently  painted  with  a  solution  of  eucain. 


2o6  REGIONAL   SURGERY 

The  general  hygiene  of  the  mouth  should  be  attended  to,  and  all  sources 
of  irritation  removed.  In  addition  the  usual  constitutional  measures 
should  be  adopted. 

SYPHILIS  OF  THE  TONGUE 

It  is  well  recognized  that  syphilis  in  its  secondary  and  tertiary  stages 
may  attack  the  tongue,  but  the  fact  that  the  primary  lesion  may  make 
its  appearance  there  is  frequently  overlooked.  The  disease  may  be 
conveyed  from  direct  personal  contact,  or  incidentally  from  drinking 
utensils,  pipes,  cigars,  cigarettes,  musical  instruments,  glass-blowers' 
pipes  and  dental  instruments. 

The  various  Hngual  lesions  met  with  in  the  disease  may  be  grouped 
as  follows: 

A.  The  primary  chancre. 

B.  The  secondary  lesions:  * 
(i)  mucous  tubercles, 

(2)  ulcers, 

(3)  fissures, 

(4)  bald  patches, 

(5)  warty  growths, 

(6)  leucomata. 

C.  The  tertiary  lesions: 
(i)  sclerosing  glossitis, 

(2)  the  formation  of  gummata. 
Primary  chancre  of  the  tongue  is  usually  seen  either  on  the  upper 
surface  or  the  edge  of  its  anterior  portion.     It  makes  its  appearance 
in  two  forms: 

1.  As  a  slightly  elevated  erosion  with  a  bright-red  base — smooth 

chancre. 

2.  As  a  hard,  indurated  ulcer  with  sloping  sides  and  foul  base. 
The  draining  lymph-glands  in  the  neck  rapidly  become  enlarged. 

This  is  a  marked  clinical  feature. 

A  primary  chancre  may  be  mistaken  for  an  epithelioma,  hut  the 
very  early  and  very  rapid  involvement  of  the  cervical  glands  will  check  a 
hasty  conclusion. 

THE  SECONDARY  LESIONS 

The  lesions  of  secondary  syphilis  on  the  tongue  are  superficial, 
multiple  and  well-nigh  symmetrical.  The  most  common  lesion  is 
the  mucous  tubercle. 


INJURIES   AND   DISEASES    OF   THE   TONGUE  207 

They  may  appear  anywhere  on  the  tongue.  They  are  multiple, 
regular  and  rounded  in  shape,  sUghtly  raised  and  whitish  in  color. 
If  irritated  by  the  teeth  they  may  ulcerate,  these  ulcers  being  s,uperficial 
with  clean-cut  edges.  Instead  of  definitely  ulcerating,  the  mucous 
tubercle  may  hecovc^Q  fissured.  If  the  irritation  continues,  the  tubercle 
may  assume  the  appearance  of  true  analcondylomata  and  become  warty. 
This  condition  is  seen  far  back  on  the  dorsum  of  the  tongue. 

Just  as  the  scalp  in  s}Tphilitic  alopecia  becomes  devoid  of  hair  in 
patches,  so  may  the  tongue  become  devoid  of  papillae,  giving  rise  to 
the  characteristic  bald  patches.  Another  lesion  seen  in  secondary 
syphilis  of  the  tongue  is  the  white  patch  called  leucoma,  aptly  hkened 
to  a  snail's  track.  Such  patches  are,  however,  more  often  seen  on  the 
back  of  the  palate  and  pharynx. 

TERTIARY  LESIONS 

The  tertiary  lesions  of  syphilis  are  sclerosing  glossitis  and  gummata. 

The  first  stage  of  both  these  varieties  is  marked  by  small-celled 
infiltrations. 

Sclerosing  Glossitis. — In  this  variety  the  small-celled  infiltration 
becomes  converted  into  fibrous  tissue  and  contracts,  converting  the 
intervening  portions  of  the  organ,  as  it  were,  into  so  many  lobules. 
The  lobules  are  painless,  firm  and  elastic.  The  fissure  may  ulcerate, 
when  the  condition  becomes  a  painful  one. 

The  process  may  remain  superficial  (superficial  sclerosing  glossitis), 
which  then  becomes  swollen  and  hard — a  condition  sometimes  called 
syphilitic  macroglossia. 

Gummata. — The  small-celled  infiltration  in  this  form  remains  local- 
ized, owing  to  diminution  of  the  blood  supply;  the  center  of  the  gumma 
softens,  breaks  down  and  ulcerates. 

Gummata  are  the  most  frequent  lesions  of  Ungual  s>^hilis.  They 
may  be  superficial  or  deep.  The  superficial  gummata  form  small, 
multiple,  knotty,  irregular  cords  on  the  dorsum;  when  they  break  down 
the  resulting  ulcers  are  long,  linear  fissures,  producing  what  is  generally 
known  as  the  "ploughed-up  dorsum"  (Fig.  iii). 

The  deep  gummata  are  generally  single;  when  they  soften  and  break 
down,  a  large  irregular  cavity  is  formed  with  steep,  rugged  borders,  a 
sloughy,  "wash-leather"  base  and  considerable  induration  of  the 
tissues  around. 

The  deep  gummata  have  a  preference  for  the  "avascular  area" 
in  the  mid-dorsal  region  of  the  tongue. 


208 


REGIONAL    SURGERY 


Diagnosis. — For  many  years  it  was  customary  to  try  to  solve  a 
doubtful  case  by  the  therapeutic  test;  at  present  it  is  usual  to  rely  on 
the  result  of  the  Wasserman  reaction.  It  is,  most  undesirable  to  depend 
on  either.  Seeing  that  a  large  percentage  of  lingual  cancers  supervene 
on  a  syphihtic  lesion,  a  positive  Wasserman  reaction  may  be  very  mis- 
leading, since  it  only  proves  the  presence  of  syphilis,  but  does  not  in- 
clude carcinoma.  The  proper  course  to  adopt  in  a  doubtful  case  is  to 
excise  a  portion  of  the  ulcer  and  submit  it  to  a  microscopic  examination. 


Fig.  III. — Syphilis  (a  gumma)  of  the  tongue. 

Treatment. — A  primary  chancre  should  be  treated  locally  with  a 
mercurial  mouth-wash. 

The  secondary  lesions  should  be  painted  with  a  weak  solution  of 
silver  nitrate,  or  a  chromic  acid  solution  (lo  grains  to  the  ounce). 

Locally,  the  tertiary  lesions  are  best  treated  with  the  chromic  acid 
solution.  Careful  attention  must  be  paid  to  the  hygiene  of  the  mouth, 
and  all  sources  of  irritation  avoided. 

Chief  reliance  in  all  syphilitic  lesions  must  be  placed  upon  the  con- 
stitutional treatment  by  a  course  of  salvarsan,  combined  with  the 
internal  administration  of  mercury  and  potassium  iodide. 


INJURIES    AND   DISEASES    OF   THE   TONGUE  209 

ACTINOMYCOSIS  OF  THE  TONGUE 

The  tongue  is  occasionally  the  seat  of  this  disease.  As  elsewhere, 
a  nodule  is  the  first  chnical  sign;  the  nodule  breaks  down  and  discharges 
through  one  or  more  sinuses,  or  forms  an  ulcer  with  undermined  edges, 
and  connected  with  pockets  hned  with  flabby  yellow-red  granulation. 

The  underface  of  the  tongue  is  usually  the  seat  of  inoculation;  the 
disease  extends  to  the  jaw,  the  muscles  and  the  neck. 

Treatment. — Wide  excision  of  the  nodule  should  early  be  adopted, 
combined  with  the  internal  administration  of  large  doses  of  potassium 
iodide,  or  copper  sulphate  as  suggested  by  Bevan. 

CERTAIN  RARE  AFFECTIONS  OF  THE  TONGUE 

Under  this  heading  will  be  described: 

1.  Wandering  rash. 

2.  Dyspeptic  tongue. 

3.  Glossodynia  exfoliativa. 

4.  Smooth  tongue. 

5.  Black  tongue. 

1.  Wandering  rash  occurs  most  frequently  in  children.  Small 
circular  or  oval  patches,  each  smooth  and  red,  appear  on  the  dorsum 
of  the  tongue.  They  are  more  commonly  found  toward  the  tip.  The 
fiHform  papillae  disappear  on  the  surface  of  the  patch,  bringing  into 
bolder  prominence  their  fungiform  colleagues.  The  diseased  process, 
subsiding  at  the  center  and  spreading  in  the  periphery,  tends  to  the 
coalescence  of  several  patches.  Thus  the  dorsum  of  the  tongue  is 
mapped  out  into  well-outlined  and  definite  smooth  areas — hence  the 
name  "geographical  tongue"  is  sometimes  applied  to  this  condition. 
According  to  Parrot  the  condition  is  probably  nervous  in  origin.  The 
condition  may  disappear  for  many  months  and  then  break  out  again. 
Treatment  is  of  no  avail. 

2.  Dyspeptic  Tongue. — This  is  a  form  of  chronic  superficial  glossitis, 
probably  due  to  some  change  in  the  saliva  rather  than  to  any  stomach 
disorder.  The  whole  of  the  front  part  of  the  dorsum  is  smooth,  de- 
prived of  papillae,  ''red  and  raw."  There  is  well-marked  increase  in 
sensibility,  hence  it  is  easily  irritated  by  trivial  injuries.  Avoidance  of 
irritating  articles  of  food  and  drink,  with  bland  applications,  is  the 
treatment  indicated. 

14 


2IO  REGIONAL    SURGERY 

3.  Glossodynia  Exfoliativa. — In  this  condition  there  is  probably 
neuralgia  of  the  lingual  nerve,  associated  with  thinning  of  the  superficial 
epithelium. 

4.  Smooth  Tongue. — This  is  not  due  to  inflammation.  The  organ  is 
deprived  of  all  its  papillae,  and  the  condition  is  analogous  to  partial  or 
complete  baldness.  "Bald  tongue"  would  express  its  nature  more 
appropriately  than  "smooth  tongue." 

5.  Black  Tongue. — In  this  rare  condition  black  spots  are  seen  on  the 
dorsum  of  the  tongue.  The  color  is  due  to  the  action  of  fungi  and 
bacilli  on  the  hair-like  processes  of  the  filiform  papillae. 


SECTION  Xll 
NEOPLASMS  OF  THE  TONGUE 

By 
SIR  H.  L.  MAITLAND,  M.  Ch.,  M.  B. 

Tumors  of  the  tongue  may  be  classified  as: 

1.  Innocent  tumors. 

2.  Malignant  tumors. 

3.  Cysts  and  tumors  of  the  thyreoglossal  tract  (lingual  goiter). 
Innocent  tumors  of  the  tongue,  with  the  exception  of  papillomata, 

are  rare.     Many  varieties  have  been  described: 

1.  Fibrolipomata. 

2.  Papillomata. 

3.  Angiomata. 

4.  Lymphangiomata. 

Fibromyomata,  congenital  chondromata  and  osteomata  have  also 
been  described.     They  are,  however,  pathological  curiosities. 

Fibrolipomata  are  very  rare;  they  may  be  superficial,  sometimes 
becoming  pedunculated,  or  may  be  situated  deeply  in  the  organ. 

Papillomata  are  the  most  common  variety  of  innocent  growth 
appearing  in  the  tongue.  They  may  appear  on  either  side  of  the  f  raenum 
in  children  during  an  attack  of  whooping  cough,  firom  irritation  by  the 
central  incisors. 

They  are,  however,  commonly  seen  complicating  the  leucoplakial 
tongue.  If  subjected  to  irritation,  they  ulcerate  and  invariably  be- 
come malignant,  a  change  which  is  ushered  in  by  induration  around 
their  base. 

All  papillomata,  especially  those  associated  with  leucoplakia,  should 
be  removed  by  two  eUiptical  incisions  enclosing  the  base,  the  resulting 
wound  being  stitched  accurately  with  silk. 

Angiomata  of  the  tongue  may  be  either  capillary  or  venous.  They 
are  generally  congenital.  The  capillary  naevi  are  seen  as  small  elevated 
patches  the  size  of  a  pea.  The  venous  na?vi  are  larger.  Both  varieties 
are  frequently  continuous  with  similar  conditions  on  the  face  and  lips. 
The  cavernous  naevi  are  bluish  in  color,  and  consist  of  groups  of  dis- 
tended veins,  which  are  easily  compressible,  filling  immediately  when 


212  REGIONAL   SURGERY 

pressure  is  removed.  The  clinical  importance  of  these  tumors  is  their 
liabiHty  to  ulceration  and  hemorrhage.  Ulceration  may  be  followed 
by  serious  septic  complications,  especially  if  the  naevi  be  of  the  venous 
variety. 

Treatment  of  Angiomata. — If  the  naevi  are  small,  they  may  be  de- 
stroyed by  Paquelin's  cautery  at  a  dull  red  heat,  or  they  may  be  excised. 

For  extensive  venous  angiomata,  the  following  Unes  of  treatment 
are  available: 

1.  Injection  of  boiling  water. 

2.  Ligation  of  vessels. 

3.  Excision  of  the  tumor. 

Injection  of  boiling  water  is  liable  to  cause  sloughing,  and  is,  there- 
fore, not  a  method  to  be  advocated.  It  should  be  reserved  for  large 
angiomata,  which  bleed  and  slough,  and  are  a  source  of  danger,  but  are 
too  extensive  to  excise.  Excision  is  the  method  to  be  chosen.  Before 
actually  excising  the  tumor,  care  must  be  taken  to  control  the  hemor- 
rhage, either  by  clamping  the  tongue  itself  or  Hgating  the  artery  of 
supply. 

Electrolysis,  except  in  very  small  naevi,  is  not  suitable  for  treatment 
of  angioma  of  the  tongue,  because  there  is  risk  that  the  needle-tract 
will  become  an  avenue  for  infection. 

Arterio-venous  aneurism  occasionally  occurs  as  the  result  of  an 
injury.     It  is  best  treated  by  tying  the  lingual  artery. 

Cirsoid  aneurism  occupying  half  the  tongue  has  been  described. 

Lymphangioma  of  the  Tongue. — This  tumor  is  not  uncommon  (Fig. 
112).  The  most  sahent  feature  of  the  condition  consists  in  dilated  and 
varicose  lymphatic  vessels  and  cavernous,  lymphatic  spaces,  and  the 
affection  is  in  all  probability  due  to  some  interference  with  the  return 
of  the  lymph  circulation.  In  this  connection  it  is  well  to  recall  that  it 
is  only  the  buccal  segment  or  the  segment  of  mandibular  origin  that  is 
affected;  the  pharyngeal  segment  is  practically  always  exempt;  and 
it  would  seem  as  if  the  obstruction  to  the  return  of  the  lymph  was  located 
at  the  boundary  line  which  separates  the  buccal  segment  from  the 
pharyngeal. 

The  tumor  is  usually  congenital,  but  may  sometimes  appear  after 
an  injury  to  the  tongue. 

On  the  tumor's  first  appearance  an  area  (variable  in  size)  of  the 
tongue  appears  to  be  covered  with  a  number  of  small  cysts,  which  are 
due  to  a  dilatation  of  the  superficial  lymphatics.  Between  the  small 
glistening  cysts  are  bright-red  points,  due  to  dilated  capillaries.     At 


NEOPLASMS  OF  THE  TONGUE 


213 


first  the  subjacent  part  of  the  tongue  is  soft.  Later  some  of  the  vesicles 
become  injured  and  rupture,  and  an  acute  glossitis  may  result;  the 
inflammatory  condition  subsides,  but  small-celled  infiltration  is  the 
result,  which  increases  the  size  of  the  tongue,  and  hardens  the  base 
of  the  tumor.  Accompanying  these  changes  is  an  increase  in  size  of  the 
blood-vessels  around  the  lymph  sinus. 

The  inflammatory  attacks  recur  at  intervals,  and  the  small-celled 
infiltration  gradually  enlarges  and  hardens  the  tongue   till   there    is 


Fig.  112. — Lymphangioma  of  one  half  the  tongue  accompanied  by  a  cavernous  naevus 

of  the  chin  and  neck. 


difficulty  in  retaining  it  within  its  oral  boundaries  (lymphangiomatous 
macroglossia). 

The  constant  pressure  of  the  tongue  may,  in  a  growing  child  cause 
marked  changes  in  the  lower  jaw.  The  alveolar  border  of  the  jaw  is 
pushed  outward  and  downward,  and  the  teeth  tend  to  become  horizontal. 

A  smaller  degree  of  macroglossia  may  arise  from  muscular  hyper- 
trophy (which  is  extremely  rare)  or  from  iiiflammalory  changes 
due  to  syphilis,  and  excessive  use  of  mercury.     These  latter  causes, 


214  REGIONAL   SURGERY 

however,  seldom  produce  changes  sufficiently  marked  to  warrant  the 
term  macroglossia. 

Treatment  of  Lymphangioma. — The  treatment  of  the  small  tumors  is 
their  destruction  by  means  of  the  Paquelin  cautery  at  a  dull  heat; 
this  method  lessens  the  danger  of  infection  and  hemorrhage,  and  is 
preferable  to  excision. 

When  the  whole  tongue  is  involved,  it  had  probably  better  be  left 
alone  till  repeated  attacks  of  inflammation  have  produced  a  typical 
macroglossia.  Then  the  only  form  of  treatment  that  offers  a  measure 
of  {success  is  the  removal  of  wedge-shaped  portions  of  the  tongue  to  re- 
duce its  mass.  Inflammation  tends  to  block  the  lymphatics,  and  there 
is  not  the  same  risk  of  a  spreading  lymphangitis. 

These  measures  should  be  adopted  before  deformity  of  the  jaw  has 
occurred. 

Malignant  Tumors  of  the  Tongue. — These  may  be  classified  as: 

1.  Sarcoma. 

2.  Endothelioma. 

3.  Carcinoma. 

Sarcoma. — This  is  a  rare  form  of  tumor  in  the  tongue. 

These  tumors  grow  rapidly,  and  ulcerate  early,  presenting  then  the 
appearance  of  a  conical  growth  with  a  central  crater-like  ulceration. 
They  are  very  vascular,  and  bleed  easily  if  injured. 

It  is  necessary  not  to  mistake  an  aberrant  thyroid  at  the  base  of 
the  tongue  for  a  sarcoma. 

Wide  excision  is  the  treatment;  but  here,  as  in  sarcoma  elsewhere, 
the  ultimate  prognosis  is  most  unfavorable. 

Endotheliomata  are  also  very  rare.  It  is  probable  that  some  of 
the  reported  cases  of  slow-growing  sarcoma  have  been  in  reality  endo- 
theliomas     They  should  be  treated  as  carcinomas. 

Cancer  of  the  Tongue. — Primary  cancer  of  the  tongue  is  always 
squamous-celled  (epithelioma). 

An  epithehoma  is  by  far  the  most  common  form  of  new  growth 
invading  the  tongue.  It  occurs  much  more  frequer^tly  in  the  male  than 
in  the  female.  In  a  series  of  300  cases  of  tongue-carcinoma  on  which  I 
operated,  only  seven  occurred  in  women.  The  explanation  of  this  dis- 
parity in  numbers  is  that  men's  mouths  are  more  frequently  the  seat  of 
precancerous  conditions. 

Precancerous  Conditions. — In  no  situation  are  precancerous  con- 
ditions so  early  recognizable  and  so  well-defined  as  on  the  tongue.  The 
importance  of  their  early  recognition  and  appropriate  treatment  can- 


NEOPLASMS  OF  THE  TONGUE  215 

not  be  over-estimated.     The    following    lesions    frequently    become 
carcinomatous: 

1.  The  wart,  especially  that  form  associated  with  leucoplakia. 

2.  The  chronic  ulcer. 

3.  The  leucoplakial  patch. 

4.  The  chronic  fissure. 

The  reason  for  early  and  active  surgical  interference  in  these  con- 
ditions is  all  the  more  urgent,  since  the  stage  of  their  transition  into 
active  malignancy  is  not  marked  by  easily  recognizable  clinical  signs. 
Induration  about  the  base  of  the  ulcer  and  wart,  or  the  edges  of  the 
fissure,  is  of  sinister  significance.  Chronic  irritation  plays  an  important 
role  as  a  predisposing  cause.  The  rough  tooth,  the  ill-fitting  dental 
plate,  the  application  of  strong  caustics  to  chronic  inflammatory  con- 
ditions of  the  tongue,  all  do  much  to  encourage  mahgnancy.  The  im- 
portance of  smoking  as  a  predisposing  cause  has  been  exaggerated,  but 
it  becomes  a  very  active  agent  in  a  tongue  made  susceptible  by 
previous  disease,  especially  by  syphilis. 

Age. — Carcinoma  most  commonly  develops  between  the  years  of 
40  and  60;  and  here,  as  elsewhere,  the  younger  the  patient  the  greater 
is  the  malignancy. 

Situation. — The  disease  may  attack  any  portion  of  the  tongue,  the 
sides  more  often  than  the  dorsum;  the  under-surface  and  tip  are  gener- 
ally exempt.  The  edge  just  in  front  of  the  anterior  pillar  of  the  fauces 
is  probably  the  site  most  often  chosen. 

Clinical  Varieties. — Cancer  of  the  tongue  in  its  initial  stages  assumes 
different  types.  This  variation  depends  mainly  on  the  form  of  the 
existent  precancerous  condition.     It  may  begin: 

1.  As  an  Ulcer. — This  variety  usually  arises  from  the  transfor- 
mation of  a  simple  chronic  ulcer  on  a  leucoplakial  patch  into  an  epi- 
theliomatous  ulcer  (Figs.  113  and  114).  The  edges  of  the  ulcer  become 
raised,  nodular  and  hard.  The  base  is  foul,  covered  with  offensive 
debris,  and  becomes  markedly  indurated.  The  ulcer  is  surrounded  by 
white  areas  of  thickened,  proliferating  epithelium.  This  type  is  prob- 
ably the  most  common.     There  is  early  glandular  involvement. 

2.  As  a  warty  mass  with  hard  base  and  edges.  This  variety  fre- 
quently originates  in  a  neglected  papilloma,  situated  upon  a  leucoplakial 
patch.  Less  often  it  may  be  malignant  from  its  inception,  although  its 
first  appearance  may  be  suggestive  of  the  benign  papilloma.  This  form 
is  of  rapid  growth,  and  fungates  early. 

^.  As  a  Fissure. — A  fissure  may  exist  in  the  tongue  from  antecedent 


2l6 


REGIONAL    SURGERY 


disease,  especially  chronic  glossitis,  syphilitic  in  origin.  Malignancy  is 
ushered  in  by  ulceration  at  the  bottom  of  the  fissure,  and  induration  of 
its  edges. 

4.  As  a  Hard  Nodule. — This  form  occurs  in  the  substance  of  the 
tongue,  beneath  the  mucous  membrane.  It  may  early  involve  the  mu- 
cous membrane,  and  ulcerate;  or  more  rarely  it  may  invade  the  whole 
of  the  muscle  of  the  organ,  making  it  hard  and  indurated — the  so-called 
"wooden  tongue."  This  form  resembles  in  its  character  atrophic 
scirrhus  of  the  breast. 

Course. — In  all  varieties  the  course  is  one  of  progressive  growth, 
both  superficially  along  the  surface  of  the  tongue  and  deeply  into  its 


Fig. 


113- 


-Leucoplakia  of  the  tongue.     The  center  has  ulcerated  and  become 
epitheliomatous. 


substance.  The  growth  is  accompanied  by  ulceration.  Later  exten- 
sion takes  place  on  to  the  floor  of  the  mouth,  sometimes  invading  the 
jaw.  If  the  disease  is  situated  in  the  posterior  third  of  the  tongue, 
there  is  early  fixation  of  the  organ,  with  extension  of  the  growth  on  to 
the  tonsil  and  soft  palate. 

Symptoms. — Slight  pain  on  mastication  may  be  the  first  symptom 
to  attract  the  patient's  attention  to  the  disease. 

Later  the  pain  becomes  severe,  and  is  transferred  from  the  lingual 
to  other  branches  of  the  fifth  nerve — especially  to  the  auriculo-tem- 
poral,  thus  causing  referred  pain  in  the  ear. 

There  is  marked  interference  with  the  functions  of  the  organ,  with 
articulation,  mastication  and  swallowing.  These  difficulties  increase 
as  the  organ  becomes  fixed.  Bleeding,  profuse  salivation,  and  marked 
foetor  of  the  breath  add  to  the  patient's  sufferings. 


NEOPLASMS  OF  THE  TONGUE  217 

The  cervical  lymph-glands  become  infected;  these  in  time  involve 
the  skin,  break  down  and  ulcerate,  and  the  patient  usually  dies  within 
two  years  from  exhaustion  due  to  repeated  hemorrhages  or  to  sepsis. 
Metastasis  to  the  liver  or  other  viscera  is  quite  exceptional. 

Infection  of  the  Ljmiphatic  System. — i.  Of  the  Glands. — Though 
it  is  difficult  to  locate  the  exact  time,  it  may  be  stated  that  the  regional 
lymph-glands  sooner  or  later  always  become  cancerous.  It  is  certain 
that  the  interval  between  the  appearance  of  the  growth  and  the  gland 
infection  varies,  even  in  persons  of  the  same  age.  As  a  rule,  the  younger 
the  patient  the  shorter  is  this  interval. 

When  considering  treatment,  however,  an  important  rule  must  be 
observed.  In  every  case  of  lingual  carcinoma  it  must  be  assumed  that 
lymphatic  infection  has  taken  place. 

2.  Of  the  Lymphatics. — Cheadle  has  demonstrated  the  presence  of 
cancer  cells  in  the  lymph  spaces  in  the  hyoglossus  and  geniohyoglossus 
muscles.  On  this  ground  it  has  been  argued  that  extension  from  the 
original  growth  takes  place  by  "permeation"  or  actual  growth  along 
the  lymph  spaces.  It  is  possible  that  such  an  argument  may  be  true. 
But  it  is  certain  that  the  most  common  method  of  extension  is  by  em- 
bolism. Squamous-celled  carcinoma  elsewhere  {e.g.,  on  the  skin)  does 
not  infect  the  lymphatics  themselves,  but  does  infect  the  glands,  and 
the  same  rule  probably  holds  in  most  cases  of  cancer  of  the  tongue. 

Extent  of  Lingual  Tissue  to  be  Excised. — On  the  pathological 
evidence  of  lymphatic  infection,  and  on  the  no  less  important  cUnical 
experience,  we  think  that  in  lingual  carcinoma  the  entire  half  of  the 
tongue  should  he  removed  when  the  growth  is  situated  laterally,  and  the 
entire  tongue  when  the  growth  is  centrally  placed.  When  the  growth  has 
invaded  the  posterior  portion  of  the  tongue,  then  the  whole  of  the  tongue 
should  be  removed.  The  removal  should  include  the  lingual  muscles 
right  down  to  the  hyoid  bone. 

Diagnosis. — It  is  only  in  cases  of  early  carcinoma  that  the  diagnosis 
is  beset  with  dif&culty.  In  the  advanced  cases  the  basal  induration, 
the  hardened  raised  edges,  the  glandular  enlargement,  all  indicate  the 
true  nature  of  the  disease. 

It  may  not  be  easy  to  distinguish  early  carcinoma  from: 

1.  A  simple  chronic  ulcer. 

2.  A  papilloma. 

3.  A  gumma. 

4.  Tuberculous  ulceration. 


2l8  REGIONAL   SURGERY 

The  difficulty  is  increased  by  the  fact  that  any  one  of  these  con- 
ditions may  become  carcinomatous. 

A  simple  chronic  ulcer  is  frequently  due  to  constant  irritation;  if 
a  cause  be  present,  such  as  a  rough  tooth  or  ill-fitting  dental  plate,  that 
is  presumptive  evidence  in  favor  of  the  benign  character  of  the  ulcer. 

A  gumma  in  its  early  stages,  before  ulceration  has  taken  place,  may 
be  confused  with  that  form  of  Hngual  cancer  which  begins  as  a  nodule 
beneath  the  mucous  membrane.  The  difficulty  in  making  an  accurate 
diagnosis  is  considerably  lessened  if  the  nodule  be  multiple,  as  it  is  not 
uncommon  to  have  more  than  one  gumma  involving  the  tongue  at  the 
same  time. 

Tuberculous  ulceration  occurs  in  younger  individuals.  A  diagnostic 
tuberculin  injection  is  of  assistance  in  a  doubtful  case. 

A  papilloma  if  it  be  sessile,  may  be  difficult  to  distinguish  from  an 
early  carcinoma;  the  difficulty  is  increased  if  ulceration  has  taken  place, 
and  there  is  some  commencing  induration. 

In  all  doubtful  cases,  however,  there  is  only  one  means  of  making 
an  early  and  certain  diagnosis,  and  that  is  by  a  microscopic  examination. 
Under  local  anaesthesia  a  portion  of  the  growth  should  be  removed, 
and  a  section  examined. 

Treatment  of  Cancer  of  the  Tongue. — The  only  treatment  that  gives 
any  prospect  of  success  is  the  complete  removal  of  the  growth  locally, 
together  with  its  glandular  draining  area.  I  wish  to  lay  particular 
stress  upon  the  necessity  of  the  removal  of  the  glandular  draining  area. 
I  consider  it  is  essential,  irrespective  of  whether  the  enlargement  of  the 
glands  is  palpable  or  not. 

The  Risks  of  Operation. — A.  Sepsis  (including  septic  pneumonia). 

B.  Hemorrhage. 

C.  Shock. 

A.  Sepsis. — The  mouth  is  always  a  septic  cavity;  and  dissection 
in  the  neck,  which  exposes  the  great  vessels  and  opens  up  the  various 
fascial  planes,  frequently  communicates  with  the  mouth,  and  renders 
sepsis  a  real  risk.  Further,  any  operation  in  the  buccal  cavity,  espe- 
cially on  the  tongue,  is  liable  to  be  followed  by  septic  pneumonia,  which 
is  certainly  the  most  common  cause  of  a  fatal  ending. 

The  danger  of  sepsis  may  be  considerably  lessened  if  certain  pre- 
cautions are  taken,  viz. : 

I.  Preliminary  Disinfection  of  the  Buccal  Cavity. — An  effort  should 
be  made  to  get  the  mouth  as  clean  as  possible.  The  brushing  of  the 
teeth  three  or  four  times  a  day,  and  the  removal  of  obviously  carious 


Fig.   114. — Cancer  of  the  tonguifr. 


NEOPLASMS  OF  THE  TONGUE  219 

ones,  are  important  preliminary  measures,  which  may  be  attended  to  a 
week  before  operation.  The  frequent  use  of  a  very  mild  antiseptic 
mouth-wash  is  also  advisable. 

2.  Preliminary  Laryngotomy. — There  is  considerable  diversity  of 
opinion  as  to  the  desirability  of  this  step.  Crile  advocates  the  use  of 
nasal  tubes  with  packing  of  the  pharynx.  Kocher  prefers  the  "hanging 
head"  position. 

I  strongly  advocate  laryngotomy  as  a  preliminary  measure,  for  the 
following  reasons: 

{a)  It  is  the  most  efl&cient  method  of  preventing  the  inspiration  of 
blood  into  the  lungs  during  the  operation.  Since  my  adoption  of  it 
12  years  ago  it  has  reduced  the  death-rate  from  septic  pneumonia  by 
75  per  cent. 

{h)  It  allows  the  operator  to  work  with  more  confidence. 

(c)  It  facilitates  the  administration  of  the  anaesthetic. 

Marine  sponges  are  used  to  plug  the  larynx,  and  the  laryngotomy 
tube  is  removed  the  day  following  the  operation. 

3.  Adequate  Drainage. — ^Liberal  drainage  should  be  provided,  espe- 
cially in  those  cases  where  the  wound  in  the  mouth  communicates  with 

th  e  neck  dissection. 

Another  means  of  limiting  the  infection — and  a  most  important 
one — is  by  judicious  stitching  of  the  soft  structures.  This  may  be 
combined  with  the  use  of  appropriately  placed  iodoform  pads. 

B.  Hemorrhage. — There  is  always  a  risk  of  this,  especially  in  the 
more  severe  operations. 

It  may  occur: 

1.  During  the  operation,  and  is  then  due  to  defective  control. 

2.  Ai^r  the  operation,  and  is  then  either  caused  by  the  slipping  of  a 
ligature,  or  it  may  be  true  secondary  hemorrhage  due  to  sepsis. 

Control  of  Hemorrhage  during  Operation. — There  are  several  meas- 
ures advocated  for  securing  control:  ^ — 

1.  Ligation  of  the  lingual  arteries  (this,  as  a  set  operation,  is  rightly 
now  seldom  adopted  as  a  means  of  controlling  hemorrhage  in  excision 
of  the  tongue. 

2.  Ligation  of  one  or  both  external  carotids. 

3.  Temporary  closure  of  both  common  carotids  with  Crile's  clamps. 
The  method  adopted,  however,  will  depend  on  the  extent  of  the 

operation. 

Ligation  of  One  or  Both  External  Carotids. — As  a  dissection  of  the 
glandular  draining  areas  of  the  neck  is  an  indispensable  complement  of 


220 


REGIONAL   SURGERY 


the  operation  for  removal  of  the  tongue,  and  the  common  carotid  and 
its  branches  are  exposed  in  clearing  the  triangle,  the  external  carotid 
can  then  he  ligated.  If  the  operation  be  a  very  extensive  one,  I  prefer 
to  adopt  Crile's  method  of  controlling  the  hemorrhage,  viz.,  temporarily 
clamping  both  common  carotids.  It  has  been  stated  that  this  is  a  danger- 
ous proceeding.  It  is  not  so.  I  have  adopted  Crile's  method  on  over 
300  occasions,  and  have  only  once  seen  hemiplegia  following  it.  I 
regard  it  as  a  perfect,  effectual  and  safe  surgical  procedure. 


Fig.  115. — Lymphatics  of  the  tongue.     Areas  likely  to  be  involved  in  cancer  of  the  tongue. 

{AJter  Leaf.) 

C.  Shock. — Shock  apart  from  blood-loss  is  not  a  salient  feature  of 
the  operation. 

An  anatomical  famiharity  with  the  position  of  the  lymphatics  of 
the  tongue,  and  of  their  collecting  trunks,  is  absolutely  essential;  other- 
wise the  necessity  for  and  limits  of  a  radical  operation  cannot  be  appre- 
ciated. 

Lymphatics  of  the  Tongue  (Fig.  115.) — There  are  two  groups: 

1.  The  submucous. 

2.  The  muscular. 

Collecting  trunks  from  these  two  groups  unite  and  form  four  sets. 

1.  The  anterior  set. 

2.  The  lateral  set. 


NEOPLASMS  OF  THE  TONGUE  221 

3.  The  posterior  set. 

4.  The  central  set. 

The  anterior  set  arises  from  the  point  of  the  tongue.  There  are 
two  sets  on  each  side  of  the  fraenum:  one  terminates  in  the  median  supra- 
hyoid group,  the  other  passes  between  the  gem'ohyoglossus  and  mylo- 
hyoid, then  crosses  the  corner  of  the  hyoid  bone,  runs  along  the  external 
border  of  the  omohyoid  muscle,  and  empties  into  a  gland  which  lies 
on  the  internal  jugular  vein  at  the  point  where  it  is  crossed  by  the  omo- 
hyoid. 

It  will  easily  be  recognized,  then,  that  in  carcinoma  of  the  tip  of  the 
tongue  there  must  be  removal  of  the  glands  as  far  down  as  the  belly 
of  the  omohyoid. 

The  lateral  set  descends  vertically  and  then  runs  transversely  with 
the  hyoglossal  nerve  over  the  external  surface  of  the  hyoglossus.  Some 
of  the  trunks  terminate  in  the  submaxillary  lymph-glands,  others  in 
the  internal  jugular  and  sterno-mastoid  chains.  The  submaxillary 
glands  are  in  very  close  relation  to  the  salivary  gland  of  the  same  name; 
hence  in  malignant  disease  it  is  necessary  to  remove  the  salivary  gland 
in  order  to  remove  the  lymph-glands  thoroughly. 

The  posterior  set  is  divided  into  minor  sets  of  collectors:  the  median, 
which  cross  frequently  from  one  side  to  another,  and  the  lateral.  Both 
sets  enter  the  internal  jugular  and  the  sterno-mastoid  chains  of 
lymph-glands. 

The  central  set  passes  between  the  geniohyoglossi  muscles  in  the 
middle  line,  and  runs  to  either  or  both  sides  of  the  neck.  The  trunks 
enter  into  the  internal  jugular  and  sterno-mastoid  chains. 

The  extent,  therefore,  of  the  dissection  of  the  neck  ought  to  include 
a  removal  of  suprahyoid,  submaxillary,  sterno-mastoid  and  internal 
jugular  groups,  from  the  omohyoid  below  to  the  highest  of  the  -internal 
jugular  group  under  the  sterno-mastoid  near  the  jugular  foramen. 

Removal  of  the  Lymphatic  Glands. — Owing  to  the  free  anasto- 
mosis of 

A.  the  central  set  of  lymphatics, 

B.  all  the  lymphatics  in  the  posterior  portion  of  the  tongue, 
the  glandular  areas  ott  both  sides  should  be  removed,  if 

(a)  the  growth  is  centrally  placed,  or 

(6)  the  root  of  the  tongue  is  invaded. 

It  sometimes  happens  that,  even  when  a  growth  is  laterally  placed, 
the  glands  on  the  opposite  side  of  the  neck  become  invaded.  Fortu- 
nately the  occurrence  is  not  common;  but,  as  it  does  occur,  it  is  wiser 


2  22  REGIONAL   SURGERY 

to  remove  the  glandular  areas  on  both  sides,  if  the  lymphatic  invasion 
is  marked  on  the  side  of  the  growth. 

Pathological  knowledge  of  the  method  of  the  spread  of  carcinoma 
in  the  lymphatic  system,  fortified  by  clinical  experience,  makes  us 
emphasize  the  fact  that  the  lymph-glands,  the  lymphatics,  the  tissues 
which  carry  them  and  the  primary  growth  should  be  removed  at  the 
one  operation. 

The  objection  to  this  procedure  is  that  the  mouth  wound  communi- 
cates with  the  neck  dissection,  and  septic  complications  are  more  likely 
to  arise.  But  the  advantages  of  removing  the  lymphatic  glands,  the 
lymphatics,  the  tissues  carrying  these  structures  and  the  original  growth 
in  continuity,  in  my  opinion,  quite  outweigh  this  objection. 

When  considering  the  treatment,  the  cases  fall  into  two  groups — ■ 
operable  and  inoperable. 

Having  decided  that  a  case  is  operable,  the  next  question  to  be  de- 
cided is  what  operation  gives  the  best  prospect  of  a  permanent  cure. 
Before  making  this  decision  certain  facts  must  be  emphasized. 

1.  Cancer  of  the  tongue,  though  generally  considered  as  spreading 
by  embolism,  may  spread  by  permeation,  and  the  lymphatics  at  the 
root  of  the  tongue  may  contain  cancer  cells  when  the  growth  is  at  the 
tip.     Any  removal  of  the  organ  must  be  down  to  the  hyoid  bone. 

2.  It  is  evident  that  any  attempt  to  remove  individual  groups  of 
glands  is  bad  surgery.  The  tissues  which  carry  the  lymphatics  and  glands 
must  he  removed. 

3.  The  infection. of  the  lymphatic  glands  with  cancer  cells  does  not 
follow  any  definite  route.  The  gland  above  the  omohyoid  may  be  the 
first  gland  involved. 

4.  The  gland  behind  the  posterior  belly  of  the  digastric  muscle,  in 
the  angle  between  the  internal  jugular  and  common  facial  veins  (the 
jugulo-digastric  gland  of  Leaf) ,  is  constantly  involved. 

5.  Equally  constant  is  the  infection  with  cancer  cells  of  the  three  or 
four  glands  lying  on  the  insertion  of  the  splenius  capitis  muscle  (the 
sterno-mastoid  chain). 

6.  The  majority  of  these  glands  are  partially  or  completely  under 
the  sterno-mastoid  muscle. 

7.  The  glands  lie  embedded  between  layers  of  cervical  fascia. 

8.  The  internal  jugular  group  lies  outside  the  sheath  of  the  deep 
vessels:  ...  by  removing  the  sheath  the  internal  jugular  vein  may 
be  left,  and  the  glands  removed. 


NEOPLASMS  OF  THE  TONGUE 


223 


9.  Thorough  removal  of  the  glandular  draining  areas  in  the  neck  is 
facilitated  by  removal  of  the  sterno-mastoid  muscle. 

Basing  myself  on  these  anatomical  and  pathological  facts,  a  personal 
experience  of  over  300  cases  of  lingual  carcinoma  operated  upon,  and 
over  1000  cases  of  dissection  of  the  contents  of  the  triangle  of  the  neck 
for  carcinoma  of  mouth-parts  generally,  I  have  come  to  the  conclusion 
that  any  operation  for  lingual  cancer,  to  give  any  hope  of  success,  must 
be  radical  and  thorough. 

I  have  been  accustomed,  for  the  last  14  years,  to  perform  one  of 
the  following  operations. 

Operations  for  Lingual  Carcinoma. — If  the  case  be  an  early  one, 
and  only  half  the  tongue  has  to  be  removed,  proceed  as  follows: 

Operation  A. — i.  An  incision  AB  is  made  from  the  mastoid  process 
to  the  middle  of  the  superior  border  of  the  thyroid  cartilage  (Fig.  116).  The 
incision  BC  is  made  upward  to  the  symphysis. 
From  the  middle  of  the  incision  AB  a.  curved 
incision  DE  is  made,  extending  downward  and 
backward  to  the  clavicle. 

The  flaps,  consisting  of  skin  and  platysma, 
are  reflected.  Their  bases  are  broad,  and  the 
blood  supply  good. 

2.  The  sterno-mastoid  muscle  is  divided 
at  the  level  of  the  omohyoid  muscle. 

3.  The  dissection  of  the  anterior,  posterior 
and  digastric  triangles  is  then  carried  out  from 
that  level  from  below  upward.     All  the  fat, 

lymph-glands' and  fascia  (in  fact  everything  in  the  area  bounded  by 
the  flaps,  including  the  sterno-mastoid  muscle)  are  removed,  except 
the  main  muscles,  vessels  and  nerves.  The  dissection  stops  when  the 
submaxillary  gland  is  reached  and  pulled  somewhat  upward. 

4.  Laryngotomy  is  performed,  plugging  the  larynx  with  soft  marine 
sponges. 

5.  The  external  carotid  is  tied  below  the  lingual  and  facial  branches. 

6.  The  attachments  of  the  lingual  muscles  to  the  hyoid  bone  are 
divided. 

7.  The  dissection  of  the  digastric  triangle  is  proceeded  with  from 
above,  and  the  buccal  cavity  is  opened  from  the  digastric  triangle  along 
the  margin  of  the  lower  jaw. 

8.  Working  partly  from  the  mouth  and  partly  from  the  neck,  half 


Fig.  116. 


2  24  REGIONAL   SURGERY 

of  the  tongue  is  excised  and  removed  in  continuity  with  the  tissues 
already  freed  by  dissection  in  the  neck. 

Operation  B. — Steps  i,  2,  3,  4  and  5  are  the  same  as  in  Opera- 
tion A. 

6.  The  inferior  maxilla  is  divided  obliquely  through  in  front  of  the 
masseter  with  a  GigU  saw.  The  sections  of  the  bone  are  pulled  apart 
by  hooks. 

7.  The  whole  of  the  buccal  cavity  is  then  easily  accessible  and  in 
plain  view,  and  the  whole  of  the  tongue  down  to  the  hyoid  bone  can  be 
removed  in  continuity  with  the  contents  of  the  triangles. 

8.  The  jaw  is  wired,  and  the  wound  is  closed.  Adequate  drainage 
to  prevent  accumulation  of  discharges  is  absolutely  essential,  and  the 
area  in  front  of  the  epiglottis  should  be  made  to  drain  directly  through 
the  lower  angle  of  the  external  wound.  The  rest  of  the  buccal  cavity 
is  shut  ojff  from  the  neck  by  stitching  together  the  mucous  membrane 
of  the  floor  of  the  mouth.  If  sufficient  mucous  membrane  is  not  avail- 
able, it  is  shut  off  by  iodoform  gauze  packing. 

9.  Dissection  of  the  other  side  of  the  neck  is  performed  at  another 
operation  a  few  weeks  later. 

This  operation  is  reserved  for  cases  in  which  the  whole  of  the  tongue 
has  to  be  removed. 

Both  these  operative  measures  are  radical  and  extensive,  and  in 
my  opinion  the  best  procedures  for  dealing  with  lingual  carcinoma. 

Reasons  for  Removing  the  Stemo-mastoid  Muscle. — i.  The  sterno- 
mastoid  group  of  lymph-glands  lies  partially  under  the  sterno-mastoid 
muscle  in  the  upper  part  of  the  neck.  The  lower  glands  of  the  group 
lie  exclusively  under  that  muscle,  while  the  internal  jugular  group  He 
for  their  entire  length  under  the  muscle. 

2.  If  the  carotid  sheath  surrounding  the  vessels  is  removed  at  the 
same  time  as  the  muscle,  then  the  glands  and  the  fascia  in  which  they 
are  embedded  come  away  in  continuity. 

3.  It  materially  simplifies  and  shortens  the  operation. 

4.  It  allows  the  superior  glands  of  the  internal  jugular  and  sterno- 
mastoid  group  to  be  easily  accessible. 

The  removal  of  one  or  both  sterno-mastoid  muscles  has  very  little 
effect  on  the  movements  of  the  head. 

If  both  muscles  are  removed,  the  head  is  carried  somewhat  more 
erect  than  usual.  The  lateral  and  nodding  movements  are  not  inter- 
fered with. 

Wry-neck  after  the  removal  of  one  sterno-mastoid  does  not  occur. 


NEOPOLASMS    OF   THE   TONGUE  225 

Mortality  of  the  Two  Operations. — Owing  to  the  varying  degrees 
of  severity  of  the  operative  measures  adopted,  it  is  difficult  to  grade  a 
series  accurately;  so  I  have  grouped  together  all  the  tongue  cases  oper- 
ated upon  by  either  of  these  methods,  and  in  a  series  of  300  cases  the 
death  rate  was  17  per  cent.  This  mortality  is  higher  than  in  less  radical 
procedures,  but  it  is  sufficiently  low  to  render  these  radical  measures 
justifiable. 

Treatment  of  Inoperable  Carcinoma. — Little  can  be  done,  except 
keeping  the  mouth  as  clean  as  possible  with  frequent  mouth  lavage; 
a  solution  of  hydrogen  peroxide  is  probably  the  best.  Pain  is  relieved 
by  morphine.  It  is  justifiable  sometimes  to  remove  a  f ungating 
carcinoma  of  the  tongue  to  relieve  local  symptoms.  The  discretion  of 
the  surgeon  and  the  wishes  of  the  patient  must,  however,  decide  this 
question. 

Radium  and  X-rays  in  lingual  carcinoma  stimulate  growth  rather 
than  lessen  it. 

I  have  not  found  Dawbarn's  starvation  treatment  of  much  avail. 

Cysts  of  the  Tongue. — Before  proceeding  to  the  thyroglossal  der- 
moids, it  is  well  to  recall  a  few  facts  in  the  developmental  history  of 
this  tract.  The  buccal  and  pharyngeal  segments  of  the  tongue  arise 
from  different  regions.  In  the  furrow  which  lies  between  these  two 
segments  of  the  developing  tongue  a  bud  of  hypoblast  proliferates  and 
forms  a  solid  outgrowth.  This,  the  median  thyroid  bud,  grows  down- 
ward and  backward,  and  after  a  time  bifurcates.  The  bifurcated 
extremity  on  each  side  redivides  repeatedly,  and  thus  is  formed  a  net- 
work of  acini,  which  eventually  become  the  isthmus  and  the  greater 
part  of  each  lateral  lobe  of  the  thyroid. 

The  so-called  thyroglossal  duct  is  nothing  more  than  the  tract  left 
by  the  descending  thyroid  bud ;  nor  is  there  any  evidence  available  that 
it  was  ever  a  functional  duct,  or  that  it  ever  conveyed  thyroid  secretion 
into  the  mouth.  In  no  animal  yet  known  does  the  duct  persist.  This 
being  so,  the  view  usually  held  (that  thyroglossal  dermoids  are  retention 
cysts  of  this  duct)  is  not  at  all  probable.  It  is  more  in  accordance  with 
observed  facts  to  regard  them  as  cysts  developed  from  aberrant  pieces 
of  thyroid  displaced  from  the  median  thyroid  bud  in  its  descent.  As 
in  the  case  of  thyroid  gland  normally  located  we  get  one  adenoma  in 
which  there  is  no  cystic  change  and  another  in  which  the  entire  growth 
undergoes  cystic  change,  so  in  the  thyroid  tumors  of  the  tongue  aber- 
rant pieces  of  thyroid  may  develop  into  cysts  or  into  tumors.  Develop- 
ing in  the  base  of  the  tongue,  thyroid  tumors  may  be  cystic,  forming 


2  26  REGIONAL   SURGERY 

the  so-called  blood-cysts,  or  may  consist  of  vascular  thyroid  tissue  and 
be  extremely  liable  to  bleed.  Fatal  hemorrhage  has  occurred  from 
these  growths. 

Other  cysts  occurring  in  the  tongue  are : 

A.  Retention  cysts  in  connection  with: 

1.  the  small  racemose  glands  in  the  posterior  part  of  the  tongue; 

2.  the   glands  of  Blandin  and  Nuhn  situated  on  the  under 
surface  near  the  lip; 

(they  form  small,  transparent  cysts  covered  with  pale  red  mucosa). 

B.  Hydatid  cysts. 

They  form  rounded,  tense,  cystic  swelUngs,  which  may  appear  in 
any  portion  of  the  organ.  They  are  seen  oftener  in  this  country  (Aus- 
tralia) than  elsewhere.   . 


SECTION  XITI 
SALIVARY  GLANDS 

By 
SIR  H.  L.  MAITLAND,  M.  Ch.,  M.  B. 

Injuries. — It  is  possible  for  any  of  the  salivary  glands  to  be  injured ; 
but  the  parotid,  on  account  of  its  comparatively  exposed  position,  is  the 
one  most  frequently  damaged. 

Accidental  wounds  of  the  parotid  gland  are  of  importance  because 
alarming  and  even  fatal  hemorrhage  may  result  from  injury  to  the  ex- 
ternal carotid  artery,  and  facial  paralysis  from  division  of  the  facial 
nerve. 

Any  of  the  glands  may  be  wounded  during  the  course  of  surgical 
operations.  Healing,  as  a  rule,  readily  follows.  If,  however,  septic 
infection  occurs,  healing  is  delayed  and  a  saHvary  fistula  may  be  es- 
tablished.    Such  a  fistula  is  usually  only  temporary. 

The  same  importance  is  not  attached  to  wounds  of  the  subhngual 
and  submaxillary  glands,  because,  if  a  permanent  fistula  should  result, 
excision  of  either  of  these  glands  is  a  simple  surgical  procedure,  invoking 
practically  no  risk  and  but  slight  disfigurement  to  the  patient. 

Treatment. — No  dead  spaces  should  be  left  when  stitching  the  wound. 
The  gland  substance  should  be  brought  into  close  apposition  by  catgut 
sutures  deeply  placed,  and  the  skin  edges  accurately  approximated. 
Pressure  should  be  appHed  by  means  of  a  bandage,  and  talking  and  mas- 
tication hmited  so  as  to  restrict  the  movements  of  the  lower  jaw  and 
secretion  of  saliva.  A  temporary  fistula  may  result  if  a  small  duct  be 
injured. 

A  penetrating  wound  of  the  parotid  may  damage  a  large  vessd, 
and  severe  hemorrhage  result.  If  such  an  accident  does  happen,  the 
wound  may  be  enlarged  transversely,  and  the  vessel  caught  in  artery 
forceps  and  tied,  the  utmost  care  being  exercised  not  to  injure  the  facial 
nerve. 

If  the  terminal  portion  of  the  external  carotid  itself  be  injured,  it 
is  safer  to  compress  it  through  the  wound  with  the  finger,  to  tie  the  ex- 
ternal carotid  at  its  origin,  and  to  plug  the  wound  in  the  parotid  to 
prevent  reflex  bleeding  from  the  upper  end  of  the  artery.     The  absence 

227 


2  28  REGIONAL   SURGERY 

of  manipulations  of  the  deeper  portion  of  the  parotid  in  this  way  avoids 
injury  to  the  facial  nerve. 

If  the  facial  nerve  has  been  divided,  an  attempt  should  be  made  to 
suture  the  ends. 

Wounds  of  Stenson's  Duct. — Since  the  direction  of  Stenson's  duct 
corresponds  to  a  line  from  the  lobule  of  the  ear  to  the  red  border  of  the 
upper  Hp,  an  injury  to  it  may  be  expected  in  deep  vertical  wounds  which 
cross  this  line.  Wounds  in  this  duct  are  usually  followed  by  a  salivary 
fistula,  which  is  extremely  difficult  to  cure.  Owing  to  its  small  caliber, 
complete  division  of  the  duct  is  the  rule.  If  the  skin  wound  heals  up,  a 
sahvary  cyst  may  form  in  the  cheek.  This  gives  rise  to  a  swelhng  which 
increases  in  size  each  time  the  patient  takes  food.  The  cyst  usually 
ruptures  externally  through  the  original  wound  and  forms  a  fistula. 

If  the  injury  to  the  duct  be  recognized  at  the  time  of  its  occurrence, 
the  divided  ends  should  be  sutured  together  with  fine  catgut.  If  the 
injury  be  in  front  of  the  masseter,  the  wound  had  better  be  deepened, 
and  the  gland  end  of  the  duct  implanted  into  the  mouth  through  an 
opening  in  the  oral  mucous  membrane,  the  external  wound  being  care- 
fully stitched  up.  If  the  original  wound  penetrates  the  mucous  mem- 
brane, then  the  external  wound  is  accurately  closed,  and  the  wound  into 
the  mouth  is  left  open,  in  the  hope  that  an  internal  fistula  will  result. 

Salivary  Fistula. — A  sahvary  fistula  is  an  abnormal  tract  through 
which  the  saliva  reaches  either  the  surface  or  the  mouth. 

The  external  fistula  is  the  only  one  of  surgical  interest,  and  occurs 
practically  only  in  connection  with  the  parotid  or  its  duct. 

An  external  fistula  is  an  exceedingly  troublesome  affliction,  the  con- 
tinual discharge  of  saliva  being  an  annoyance,  which  is  increased  by 
the  chronic  eczema  produced  by  the  constant  wetting  of  the  skin. 

Salivary  fistula  may  arise: 

1.  In  connection  with  the  gland. 

2.  In  connection  with  the  duct. 

Gland  Fistula. — If  it  arises  in  connection  with  the  gland  itself,  it 
will  probably  close  in  a  few  weeks  or,  at  the  most,  months. 

The  only  symptom  present  is  the  exudation  of  varying  amounts  of 
saliva  from  the  wound. 

Duct  Fistula. — The  fistula  of  Stenson's  duct  may  follow  a  wound, 
and  less  frequently  impacted  stone,  abscess,  syphilitic  or  tuberculous 
ulceration,  rodent  ulcer  and  actinomycosis.  A  fistula  of  this  duct 
causes  much  inconvenience  and  is  frequently  permanent,  unless  opera- 
tive aid  is  successfully  given. 


SALIVARY   GLANDS  229 

The  small  sinus,  usually  surrounded  by  a  bud  of  granulation  tissue, 
is  most  frequently  situated  anterior  to  the  margin  of  the  masseter 
muscle. 

Treatment  of  Salivary  Fistulae. — i.  Of  Gland  Fistula. — The  tendency 
of  these  fistulae  is  to  heal.  If  the  cure  be  delayed,  the  appUcation  of 
the  galvano-cautery  should  be  tried.  This  minor  operative  measure  is 
usually  successful.  If  it  fails,  the  fistulous  tract  had  better  be  excised, 
and  the  gland  tissue  carefully  stitched  with  deep  and  superficial  sutures. 

2.  Of  Duct  Fistula. — If  a  fistula  has  not  become  permanent,  it  may 
be  cured  by  repeated  cauterization  of  the  sinus,  either  by  heat  or  by  a 
pencil  of  silver  nitrate. 

If  it  has  become  permanent,  it  is  extremely  obstinate  and  difficult 
to  cure,  and  resort  must  be  had  to  one  of  the  operative  measures.  These 
measures  have  been  based  on  different  principles,  which  vary  according 
to  the  situation  and  severity  of  the  fistula. 

1.  By  Restoring  the  Normal  Route. — Expose  the  duct,  excise  the  scar, 
dilate  the  distal  end,  and  close  the  defect  with  a  catgut  suture. 
Cover  in  the  wound  with  a  plastic  skin  flap. 

2.  By  Converting  the  External  Fistula  into  an  Internal  One. — 

(a)  Von  Langenbeck's  operation. 

(b)  Deguise's  operation. 

(c)  Kaufman's  operation. 

(d)  Plastic  formation  of  new  duct  (Braun's  operation). 

3.  By  removal  of  the  gland,  thus  preventing  the  secretion  of  saliva. 
This  measure  should  only  be  undertaken  as  a  last  resort.  The 
facial  nerve  should  be  carefully  dissected  out  and  isolated  to 
prevent  injury,  and  then  as  much  of  the  gland  as  possible  should 
be  removed. 

Selection  of  Method. — Direct  union  by  suture  should  be  the  method 
chosen  for  all  fistulse  of  the  buccal  portion  of  the  duct.  If  the  result 
te  unsuccessful,  then  either  the  operation  suggested  by  Deguise  or  by 
Kaufman  is  to  be  recommended.  If  the  fistula  be  in  the  masseteric 
portion,  it  is  obvious  that  the  Deguise  method  is  not  suitable,  as  the 
masseter  would  be  included  in  the  hgature.  If  the  fistula  be  in  this 
situation  and  direct  suture  has  failed,  either  Kaufman's  or  the  "plastic" 
operation  of  Braun  should  be  tried.  If  the  fistula  is  situated  near  the 
parotid,  all  measures  usually  fail.  If  direct  suture  be  not  a  success, 
partial  resection  of  the  gland  is  the  only  method  that  will  relieve  the 
distressful  symptoms. 

If  a  permanent  external  salivary  fistula  should  occur  in  connection 


230  REGIONAL   SURGERY 

with  Wharton's  duct,  all  inconvenience  can  be  avoided  by  removal  of 
the  submaxillary  gland. 

INFECTIVE  CONDITIONS 

Inflammation  of  the  Salivary  Gland  {Sialo-adenitis) . — Some  doubt 
still  surrounds  the  etiology  of  inflammation  of  the  saHvary  gland. 
Recent  investigations,  however,  make  it  seem  probable  that  all  non- 
specific inflammations  have  their  origin  in  the  mouth,  and  ascending 
the  excretory  duct  infect  both  it  and  the  corresponding  gland. 

With  acute  primary  sialo-adenitis  (parotitis  or  mumps)  we  are  not 
directly  concerned,  as  it  belongs  to  the  domain  of  the  physician. 
.  Acute  Secondary  Sialo-adenitis. — The  mouth  is  the  habitat  ot 
multitudes  of  microorganisms.  The  fact  that  they  are  usually  inert  is 
attributed  to  the  action  of  the  saliva.  Any  cause — such  as  pyrexia — 
which  inhibits  the  salivary  flow  tends,  therefore,  toward  increased  activ- 
ity of  the  microorganisms  in  the  mouth,  and  increases  the  danger  of  an 
ascending  parotitis. 

The  impaction  of  a  calculus  in  the  excretory  duct,  abnormal  condi- 
tions of  the  mouth  (such  as  stomatitis,  especially  the  form  due  to  mer- 
cury) and  sepsis  are  not  uncommon  causes  of  the  disease.  It  may  also 
accompany  any  of  the  specific  infectious  fevers,  especially  typhus  and 
typhoid. 

Post-operative  Parotitis. — This  uncommon  variety  is  seen  some- 
times following  operations,  usually  abdominal.  There  are  several 
possible  contributing  factors:  the  temperature  in  septic  cases,  the  opera- 
tion itself,  or  the  cessation  of  mouth-feeding  may  all  predispose  the 
mouth  to  dryness  from  diminished  salivary  secretion — a  fact  which,  as 
I  have  pointed  out,  greatly  increases  the  activity  of  the  buccal  bacteria. 

This  form  of  parotitis  appears  generally  between  the  fifth  and  the 
eleventh  day  after  the  operation,  and  is  characterized  by  considerable 
swelling  and  intense  pain.  The  movements  of  the  jaw  early  become 
restricted  and  painful.  There  is  marked  difficulty  in  swallowing  and 
opening  the  mouth. 

It  may  end  in  resolution  about  the  fourth  day  or  (which  is  mare 
common)  may  go  on  to  suppuration.  When  this  occurs,  the  severity 
of  the  symptoms  increases;  the  whole  parotid  becomes  tense  and  greatly 
swollen,  the  skin  red,  oedematous  and  adherent,  and  the  entire  face 
swollen. 

If  the  presence  of  suppuration  be  overlooked,  disastrous  results  may 
follow.     Pus  may  burrow  into  the  temporo-maxillary  joint,  or  into  the 


SALIVARY   GLANDS  23 1 

external  auditory  meatus.  It  may  work  upward  toward  the  base  of  the 
skull,  or  form  a  retropharyngeal  abscess,  or  find  its  way  downward 
through  the  tissues  of  the  neck.  Large  vessels  in  the  gland  may  be- 
come eroded,  leading  to  severe  hemorrhage.  The  facial  nerve  may  be 
destroyed,  with  consequent  permanent  facial  palsy.  Salivary  fistulae 
may  form.  Septic  thrombosis  of  the  internal  jugular  vein  may  ensue, 
and  death  from  sepsis  result. 

The  submaxillary  and  sublingual  glands  are  rarely  subject  to  in- 
flammation, except  as  the  result  of  an  impacted  stone. 

Treatment. — When  inflammation  of  the  salivary  glands  occurs,  the 
frequent  application  of  heat  in  the  form  of  fomentations  gives  relief. 
Remove  the  cause  of  the  inflammation,  and  carefully  attend  to  the  hy- 
giene of  the  mouth.  When  suppuration  takes  place,  the  salivary  gland 
involved  should  be  incised,  and  the  pus  evacuated.  If  it  occurs  in  the 
parotid,  a  small  horizontal  incision  should  be  made  behind  the  angle 
of  the  jaw,  the  gland  capsule  opened,  and  a  communicating  channel 
made,  by  means  of  a  sinus  forceps,  between  the  suppurating  focus 
and  the  incision.  This  should  be  sufiiciently  large  to  permit  of 
adequate  drainage.  If  the  submaxillary  gland  be  at  fault,  the  incision 
should  be  made  beneath  the  jaw,  and  placed  so  as  to  avoid  the  facial 
artery. 

Chronic  Inflammation  {Chronic  Sialo-adenitis) . — This  seldom  occurs 
in  the  parotid,  but  is  not  uncommon  in  the  submaxillary  glands.  It  is 
generally  associated  with  impacted  stone.  The  best  treatment  is  to 
remove  the  gland. 

Inflammation  of  the  Excretory  Ducts  {Sialodochitis). — This  condi- 
tion is  generally  associated  with  inflammation  of  the  corresponding 
gland,  and  has  the  same  etiology  as  acute  sialo-adenitis;  but  there  are 
forms  which  may  be  limited  to  the  duct  itself.  It  most  commonly  af- 
fects Stenson's  duct,  and  may  lead  to  a  thickening  of  the  walls  of  the 
duct,  and  a  narrowing  of  its  lumen  with  periodic  blockage  from  plugs 
of  mucus.  The  symptoms  much  resemble  those  produced  by  salivary 
calculi.  The  only  treatment  of  avail  is  to  slit  up  the  narrowed  duct 
from  its  orifice,  so  as  to  provide  a  free  opening  into  the  mouth. 

Salivary  Calculi. — These  are  more  often  found  in  the  excretory 
ducts  than  in  the  glands  themselves.  The  situation  of  Wharton's  duct, 
its  length  and  width  and  the  position  of  its  orifice,  probably  accounts 
for  the  fact  that  it  is  the  site  most  often  affected.  The  next  most  com- 
mon situation  is  the  submaxillary  gland  itself.  Calculi  usually  appear 
singly  if  situated  in  the  duct,  but  are  frequently  multiple  if  in  the  gland. 


232  REGIONAL   SURGERY 

They  are  more  often  found  in  men  than  in  women,  and  generally  occur 
during  middle  age. 

The  calculi  vary  in  size,  but  usually  do  not  exceed  the  size  of  a  pea. 
The  color  is  grayish  white  (sometimes  darker)  and  the  surface  rough. 
They  are  hard  in  consistence.  If  formed  in  the  duct,  the  shape  is  elon- 
gated or  cylindrical;  if  in  the  gland,  it  is  irregular. 

A  saHvary  stone  consists  of  inorganic  Hme  salts  (chiefly  carbonate 
and  phosphate  of  Hme)  in  an  organic  framework  consisting  chiefly  of 
mouth  bacteria.  The  presence  of  these  bacteria  is  not  accidental,  as 
their  action  on  the  saliva  is  responsible  for  the  formation  of  the  concre- 
tion. The  origin  of  the  calculi  is  thus  very  similar  to  that  of  the  tartar 
of  the  teeth.  A  foreign  body  may  play  some  role  in  their  formation 
— a  fishbone,  a  fruit  seed,  or  a  small  piece  of  tartar  occasionally  forms 
the  nucleus  of  the  concretion.  Calculi  may  give  rise  to  considerable 
inflammation  in  the  duct  and  gland,  which  in  the  case  of  the  sub- 
maxillary gland  may  go  on  to  the  formation  of  an  abscess.  If  an  ab- 
scess develops  and  ruptures  into  the  mouth,  the  resulting  sinus  may 
simulate  an  epithelioma. 

Instead  of  a  localized  abscess  a  progressive  inflammation  may  ensue 
after  the  stone  has  caused  ulceration  of  the  duct.  The  inflammation 
not  infrequently  appears  in  the  floor  of  the  mouth,  and  may  extend  to 
the  neck. 

In  the  majority  of  cases  a  chronic  interstitial  inflammation  of  the 
gland  is  set  up  and  it  becomes  hard,  firm  and  adherent  to  the  surround- 
ing structures,  simulating  a  malignant  tumor. 

Symptoms. — Symptoms  may  not  make  their  appearance  for  some 
years,  until  the  stone  partially  blocks  the  duct  or  inflammation  in  the 
duct  or  gland  is  set  up. 

The  most  characteristic  symptom  is  the  periodic  appearance  of  a 
salivary  tumor,  accompanied  by  pain.  These  symptoms  are  increased 
at  the  sight  of  food  or  during  a  meal.  This  pain  has  aptly  been  termed 
"saHvary  colic,"  and  is  due  to  the  increased  outflow  of  the  saliva  being 
obstructed  by  a  calculus  impacted  in  the  duct.  If  the  calculus  does 
not  completely  block  the  duct,  the  swelling  disappears  between  meals. 
If,  however,  the  duct  be  completely  obstructed,  a  retention  cyst  is 
formed,  which  soon  becomes  infected  and  suppurates.  Another  marked 
symptom  is  pyorrhoea  salivalis.  If  the  gland  be  squeezed,  pus  is  seen 
to  issue  from  the  gaping  orifice  of  the  duct. 

The  diagnosis  can  usually  be  made  by  bimanual  palpation,  by  pass- 
ing a  probe  up  the  duct,  or  by  introducing  a  needle  into  the  suspected 
site.     CalcuH  may  also  be  detected  by  means  of  the  Rontgen  rays. 


SALIVARY   GLANDS  233 

Treatment.— When  the  calculus  is  in  Stenson's  duct  it  is  generally 
lodged  near  the  orifice  and,  under  local  anaesthesia,  can  easily  be  re- 
moved by  sHtting  up  the  canaliculus  and  expressing  the  stone.  A  simi- 
lar procedure  can  be  adopted  if  the  calculus  is  near  the  orifice  of  Whar- 
ton's duct.  If,  however,  the  stone  is  more  deeply  placed,  a  general 
anaesthetic  had  better  be  given,  the  stone  fixed  by  pressing  it  against 
the  ramus  of  the  jaw,  and  then  cut  down  upon.  No  attempt  should 
be  made  to  stitch  up  the  duct.  The  only  after-treatment  required  is 
the  frequent  use  of  an  antiseptic  mouth-wash. 

If  the  stones  are  situated  in  the  subHngual  or  submaxillary  glands, 
or  if  these  glands  have  become  infected  and  chronically  inflamed,  then 
the  entire  gland  had  better  be  extirpated. 

Actinomycosis  of  the  salivary  glands  is  not  common,  and  is  due  to 
infection  from  foci  in  the  neighborhood. 

Tuberculosis  of  the  salivary  glands  is  a  very  rare  affection.  It  is 
generally  primary.  The  diagnosis  is  extremely  difl&cult.  This  disease 
has  been  mistaken  for  a  gumma,  a  sarcoma  and  a  "mixed  tumor."  If 
a  cold  abscess  forms,  it  may  be  mistaken  for  a  dermoid  or  a  salivary 
cyst. 

Treatment. — The  complete  removal  of  the  submaxillary  and  the 
partial  removal  of  the  parotid  gives  a  very  favorable  prognosis. 

Syphilis  of  the  salivary  glands  is  rare,  but  is  more  frequent  than 
tuberculosis.     It  appears  in  two  forms: 

1.  An  interstitial  fibrous  variety. 

2.  A  gummatous  formation. 
The  latter  is  more  common. 

Symmetrical  Disease  of  the  Lachrymal  and  Salivary  Glands. — 
This  condition  was  first  described  by  MikuHcz,  and  has  been  given  his 
name.  It  begins  in  early  adult  life;  the  salivary  glands  slowly  enlarge, 
remain  confined  to  their  capsules  and  form  firm  movable  tumors.  The 
disease  may  be  accompanied  by  swelling  of  the  lymphatic  glands  and 
spleen. 

The  etiology  is  obscure. 

Arsenic  and  iodide  of  potassium  have  been  recommended  as  thera- 
peutic agents. 

Tumors  of  the  Salivary  Glands. — Tumors  of  the  sahvary  glands  are 
of  very  great  interest;  an  important  group,  the  "mixed  tumors,"  has 
long  been  a  pathological  puzzle.  The  tumors  of  the  three  salivary 
glands  are  pathologically  alike  and  may  be  classified  as: 

I.  Connective-tissue  tumors. 


234 


REGIONAL    SURGERY 


2.  Epithelial  tumors. 

3.  (Of  both  epithehal  and  connective- tissue  origin.)  The  so-called 
"mixed  tumors." 

Connective-tissue  Tumors. — Angioma,  lymphangioma,  fibroma, 
myxoma,  Hpoma,  chondroma,  sarcoma. 

All  these  tumors  are,  comparatively  speaking,  uncommon  and  do 
not  present  any  peculiar  features;  many  of  them  should  probably  be 
classified  as  "mixed." 

If  the  tumor  be  diagnosed  as  sarcoma,  especially  melanosarcoma, 
the  whole  gland  should  be  excised. 

Epithelial  Tiunors. — Adenoma,  carcinoma. 

Adenomata  are  comparatively  rare. 

Carcinomata,  next  to  the  "mixed  tumor,"  are  the  most  common  of 


Fig.  1 17. — Scirrhus  of  the  parotid  showing  contraction  of  the  tissues  surrounding  the  tumor 

tumors.  The  parotid  is  more  often  affected  than  other  salivary  glands. 
They  occur  in  two  forms:  (a)  the  adenocarcinoma;  {h)  the  scirrhus. 

In  adenocarcinoma  the  tumor  is  of  soft  consistence.  The  growth  is 
rapid.  The  skin  presents  at  first  a  tense  glistening  appearance,  but  soon 
becomes  involved  and  ulcerates. 

Scirrhus  of  the  parotid  resembles  the  mammary  form.  The  out- 
standing feature  is  contraction  of  the  tissues  surrounding  the  tumor. 
(Fig.    117).     Occasionally    the   skin    overlying    the  growth  becomes 


SALIVARY   GLANDS  235 

markedly  involved,  and  converted  into  a  thick  leathery  covering, 
comparable  to  cancer  en  cuirasse  of  the  breast. 

The  marked  cicatricial  contraction  in  this  form  of  carcinoma  ac- 
counts for  the  early  involvement  of  the  facial  nerve. 

Symptoms. — In  both  forms  pain  is  usually  present;  as  the  disease 
advances  it  becomes  severe,  hearing  is  interfered  with,  and  there  is 
difficulty  in  swallowing  and  speaking,  and  in  all  movements  of  the 
mandible. 

The  adenocarcinoma  is  very  malignant,  and  runs  a  fairly  rapid 
course.     The  scirrhus  is  not  so  malignant  and  is  of  slow  growth. 

The  early  diagnosis  of  carcinoma  of  the  salivary  glands  presents 
many  difficulties. 

To  differentiate  between  a  chronic  inflammatory  swelling  and  a 
carcinoma,  especially  of  the  submaxillary  gland,  is  not  always  easy. 
Facial  paralysis  is  a  symptom  of  the  utmost  importance  in  diagnosing 
carcinoma  of  the  parotid,  but  unfortunately  it  is  not  an  early  symptom. 

Tubercle  and  syphilis  also  have  to  be  considered  in  making  a 
diagnosis. 

The  rare  cases  of  adenocarcinoma  of  the  floor  of  the  mouth  originate 
in  the  sublingual  gland. 

The  treatment  is  the  total  extirpation  of  the  glands  at  fault,  together 
with  their  glandular  draining  areas. 

Extirpation  of  the  submaxillary  gland  is  not  difficult.  It  entails  a 
dissection  of  the  submaxillary  triangle.     The  steps  are: 

1.  Incision  through  the  skin  and  platysma,  as  in  dissection  of  sub- 
maxillary triangle  in  the  operation  for  removal  of  the  cervical  glands. 

2.  Raising  the  flap,  and  division  of  facial  vein  and  artery  between 
double  ligatures. 

3.  Lifting  the  gland  from  its  fascial  compartment,  and  tying  its 
excretory  duct. 

4.  Separating  it  from  its  mesial  and  upper  attachments  along  the 
jaw,  clamping  and  tying  the  facial  artery  and  vein  as  they  pass  over  the 
lower  jaw. 

If  the  gland  is  removed  for  malignant  disease,  its  removal  should  be 
accompanied  by  a  dissection  of  the  glandular  draining  area  of  that  side 
of  the  neck,  as  I  have  recommended  in  lingual  carcinoma. 

Extirpation  of  Sublingual  Gland. — Carcinoma  of  this  gland  is  not 
usually  recognized  till  the  floor  of  the  mouth  is  extensively  involved; 
an  operation  similar  to  that  for  removal  of  the  floor  of  the  mouth  is 
then  necessary. 


236  REGIONAL   SURGERY 

Extirpation  of  the  parotid  for  carcinoma  is  a  difficult  operation.  As 
it  is  necessary  to  remove  the  capsule  as  well  as  the  gland,  I  am  of 
opinion  that  to  do  it  in  a  satisfactory  manner  the  ramus  of  the  jaw  must 
be  removed;  otherwise  it  is  quite  impossible  to  remove  the  gland  thor- 
oughly from  the  retromandibular  fossa. 

Another  important  point  is  to  obtain  absolute  control  of  the  hemor- 
rhage, an  end  best  achieved  by  tying  the  external  carotid,  or  by  tempor- 
arily clamping  the  common  carotid.  The  facial  nerve,  of  course,  must 
be  sacrificed. 

Steps  of  Operation. — Step  i. — Skin  incisions  as  in  Fig.  118.     Rais- 
ing the  flaps. 

Step  2. — Begin  dissection  from  below, 
doubly  ligature  the  external  carotid  near  its 
origin,  and  divide  it.  The  distal  portion  of 
the  vessel  is  removed  with  the  gland.  Isolate 
the  internal  jugular  vein,  and  remove  the 
lymph-glands  of  the  internal  jugular  chain. 

Step  3. — Divide  the  ramus  of  the  jaw, 
and    disarticulate  it   at   its    upper  extremity. 

^         o  Then  from  above  downward  and  from  in  front 

Fig.  118. 

backward  remove  the  whole  of  the  parotid 
together  with  the  ramus  of  the  jaw. 

Step  4. — Tie  off  the  vessels  and  complete  the  toilet,  providing  drain- 
age. In  extensive  cases  it  may  be  advisable  to  perform  laryngotomy 
and  plug  the  larynx.  If  the  general  condition  of  the  patient  be  good, 
a  complete  dissection  of  the  glandular  areas  may  be  performed  at  the 
same  time.     If  not,  it  is  done  2  or  3  weeks  later. 

Mixed  Tumors. — The  most  common  growth  of  the  salivary  glands  is 
the  "mixed  tumor."  As  a  rule  these  tumors  are  circumscribed  and 
well-defined,  and  sometimes  attain  a  considerable  size. 

They  form  nodular  elastic  swellings  of  uneven  consistency,  which 
either  grow  slowly  or  remain  quiescent  for  some  years,  and  then  sud- 
denly take  on  a  vigorous  and  active  growth,  burrowing  deeply  into  the 
gland,  invading  the  surrounding  structures  and  destroying  life.  The 
tumors  are  usually,  but  not  always,  encapsuled.  The  capsule  to  a  great 
extent  disappears  when  they  take  on  a  sudden  and  rapid  increase  in 
growth.  They  are  more  common  in  the  parotid  than  in  the  submax- 
illary, and  are  rare  in  the  sublingual  gland. 

They  may  grow  from  any  portion  of  the  parotid,  the  lower  and  an- 


SALIVARY    GLANDS 


The  ex- 


terior segment  of  the  gland  being  the  site  usually  selected, 
tension  of  growth  is  then  downward  into  the  neck  (Fig.  119). 

If  they  arise  in  the  center  of  the  gland,  they  may  obliterate  the 
auditory  meatus,  or  may  fill  the  submaxillary  fossa  and  extend  toward 
the  pharynx.  If  the  submaxillary  be  the  gland  invaded,  the  growth 
usually  starts  from  the  superficial  surface,  and  projects  from  beneath 
the  jaw  rather  than  toward  the  mouth. 

These  tumors  contain  a  variety  of  tissues,  such  as  fat,,  cartilage, 


Fig.   119. — Mixed  tumor  of  the  parotid  which  grew  slowly  for  11  years. 

myxomatous  and  lymphoid  tissue,  while  the  parenchyma  cells  are  those 
peculiarly  flattened  ones  called  endothelium.  Hence  the  "mixed 
tumor"  is  an  endothelioma. 

Treatment. — It  is  a  well-recognized  fact  that  if,  when  removing 
these  tumors,  the  capsule  is  opened  and  left  there  is  danger  of  a  rapid 
and  more  active  recurrence.  It  is,  therefore,  necessary  to  remove  the 
growth  plus  its  capsule. 

A  suitably  placed  incision  should  be  made;  for  small  tumors  an 
incision  parallel  to  the  branches  of  the  facial  nerve  is  generally  adequate. 
The  capsule  of  the  tumor  is  exposed;  then,  working  outside  the  capsule, 
chiefly  by  blunt  dissection,  the  tumor  plus  its  capsule  is  separated  from 
its  connections  and  removed. 

If  the  tumor  is  more  extensive,  and  has  taken  on  active  malignant 


238  REGIONAL   SURGERY 

growth,  breaking  through  the  capsule,  the  whole  of  the  gland  should 
be  widely  removed.  An  endeavor  to  save  the  facial  nerve  will  generally 
end  in  the  performance  of  an  incomplete  operation,  with  rapid  recur- 
rence of  the  disease. 

CYSTS  OF  THE  SALIVARY  DUCTS 

Ranula. — The  term  is  usually  applied  to  any  cyst  in  the  floor  of  the 
mouth;  b\it  it  is  better  to  restrict  the  term  to  cysts  arising  in  connection 
with  the  ducts  of  the  salivary  glands.  A  ranula  associated  with 
Stenson's  duct  is  rare,  but  one  connected  with  either  the  lingual  or  the 
submaxillary  gland  is  common.  The  cysts  are  rounded,  translucent, 
and  of  a  grayish  red  color,  occupying  the  furrow  between  the  gums  and 
the  tongue;  if  only  moderate  in  size  they  project  into  the  floor  of  the 
mouth,  if  large  they  become  prominent  beneath  the  lower  jaw  in  the 
submaxillary  triangle.  The  cysts  are  monolocular,  and  are  filled  with  a 
viscid  fluid  resembhng  egg  albumen. 

The  etiology  of  ranulse  is  not  always  evident.  They  may  be  con- 
genital in  origin,  or  may  be  due  to  blockage  of  the  duct  by  a  calculus 
or  cicatricial  contraction. 

Treatment. — The  only  method  which  gives  any  permanent  result  is 
extirpation  of  the  ranula.  If  the  cyst  be  small,  the  mucous  membrane 
is  divided  under  local  anaesthesia,  and  the  cyst  is  removed  by  blunt  dis- 
section. If  the  ranula  is  large  and  projects  beneath  the  jaw,  its  removal 
had  better  be  done  from  beneath  the  chin. 

Small  ranulae  may  sometimes  be  cured  by  excising  the  anterior  wall, 
painting  the  cavity  of  the  cyst  with  iodine,  and  keeping  the  cavity 
plugged  with  gauze. 

CYSTS  OF  THE  SALIVARY  GLANDS 

Retention  cysts  may  form  in  the  glands  themselves.  If  there  be 
some  hindrance  to  the  free  outflow  of  saliva,  the  gland  atrophies,  and 
in  whole  or  part  of  it  becomes  a  cyst. 

The  treatment  is  excision.  When  this  is  not  practicable,  the  cyst 
may  be  opened  and  allowed  by  plugging  to  granulate  up  from  the 
bottom. 


SECTION  XIV 
SURGICAL  DISEASES  OF  THE  PHARYNX 

By 

JOSEPH  L.  GOODALE,  A.  M.,  M.  D. 

Boston,   Mass. 

1.  Acute  infections  and  traumatic  processes. 

2.  Chronic  infections. 

3.  Hypertrophy  of  the  faucial  tonsils. 

4.  Neoplasms. 

I.  INFECTIOUS  OR  TRAUMATIC  PROCESSES 

By  this  term  is  denoted  those  inflammations  of  the  tissues  directly 
dependent  upon  bacterial,  chemical  or  physical  irritants. 

The  larger  number  of  acute  infections  of  the  pharynx  originate  in 
the  lymphoid  tissue  of  the  tonsils  and  of  the  posterior  pharyngeal  wall. 
Their  chnical  characteristics  depend  primarily  upon  the  intensity  of  the 
irritation  excited  by  the  toxine  generated  as  well  as  upon  the  locaKza- 
tion  of  the  microorganisms.  Where  the  toxine  is  mild,  the  inflammation 
is  a  proliferative  one,  characterized  by  reddening  and  swelling  of  the 
mucous  membrane,  with  emigration  of  leucocytes  into  the  crypts  of 
the  lymphoid  tissue.  Where  the  toxine  is  stronger,  the  inflammation 
presents  evidence  of  exudation,  due  to  coagulation  of  the  albuminous 
elements  in  the  cells  and  in  the  surface  fluids,  being  then  characterized 
by  the  formation  of  a  false  membrane.  If  the  microorganisms  have 
penetrated  below  the  surface  of  the  tissue,  they  may  undergo  multipli- 
cation within  the  follicles,  producing  minute  abscesses,  which  under 
ordinary  circumstances  proceed  to  develop  in  the  line  of  least  resistance, 
and  eventually  rupture  into  the  crypts,  with  a  consequent  establish- 
ment of  convalescence.  If  the  rupture  of  these  abscesses  takes  place, 
however,  in  the  direction  of  the  efferent  lymph  channels,  the  organisms 
are  transported  into  the  circumtonsillar  fat  tissue,  under  which  circum- 
stances an  abscess  formation  or  quinsy  is  probable.  If  the  organisms 
penetrate  further,  they  may  cause  swelling  and  suppuration  of  the  cer- 
vical lymph  nodes,  or  they  may  enter  the  circulation  and  cause  inflam- 
mation of  the  joints,  endocardium  and  kidney,  or  a  general  septicemia. 

239 


240  REGIONAL   SURGERY 

In  ordinary  forms  of  acute  proliferative  or  exudative  inflammation, 
the  aid  of  the  surgeon  is  not  required.  It  may  be  possible  at  the  outset 
to  abort  the  disease  through  appropriate  treatment,  such  as  the  ad- 
ministration of  hexamethylenamine  and  the  salicylates,  with  the  local 
application  of  argyrol,  collargol  or  silver  nitrate.  If,  however,  the 
condition  is  recognized  only  after  the  establishment  of  pronounced 
inflammation,  such  treatment  may  not  shorten  the  duration  of  the  dis- 
ease, although  the  symptoms  of  discomfort  may  be  considerably 
relieved.  In  fact  active  measures  designed  to  sterilize  the  mucous  sur 
faces  may  possibly  actually  prolong  the  period  required  for  convales- 
cence. It  must  be  remembered  that  the  recovery  is  effected  under 
natural  conditions  through  the  establishment  of  an  active  immunity, 
induced  by  the  absorption  of  a  sufficient  amount  of  toxine  into  the  sys- 
tem, and  the  consequent  formation  within  the  system  of  antibodies. 
Anything,  therefore,  which  tends  to  check  the  production  of  toxine, 
is  calculated  to  prolong  the  period  required  for  the  manufacture  of  a 
sufficient  quantity  of  antitoxine.  The  continued  application  of  anti- 
septics consequently  produces  the  reverse  of  what  is  sought  to  accom- 
plish by  the  injection  into  the  body  of  specific  vaccines.  The  most 
important  treatment  which  can  be  brought  to  bear  upon  the  process 
is  complete  local  and  general  rest.  Local  applications  should  be  de- 
signed to  cleanse  the  parts  mechanically  rather  than  to  sterilize  them. 

If  the  inflammation  has  proceeded  to  abscess  formation,  this  may 
be  situated  either  within  the  tonsil,  due  to  the  coalescence  of  a  number 
of  the  intrafollicular  abscesses  above  mentioned,  or  in  the  circumtonsil- 
lar  fat  tissue. 

In  the  first  instance,  reasonably  prompt  relief  is  apt  to  occur  spon- 
taneously through  the  rupture  of  the  abscess  into  one  or  more  crypts, 
and  surgical  intervention  may  not  be  necessary.  On  the  other  hand, 
if  the  abscess  has  developed  in  the  neighborhood  of  the  tonsil,  it  is 
bounded  by  relatively  firm  fascia  which  render  spontaneous  evacuation 
difficult,  and  incision  may  be  consequently  necessary.  In  the  majority 
of  instances  the  pus  is  nearest  the  surface  at  a  point  midway  between 
the  base  of  the  tonsil  and  the  condyle  of  the  jaw,  and  is  most  easily 
reached  by  incising  the  anterior  plica  and  dissecting  around  the  cap- 
sules. For  local  anaesthesia  one  may  introduce  into  the  crypts,  by  a 
pliable  silver  cannula,  a  few  drops  of  a  dilute  cocaine  and  adrenaline 
solution.  This  preparation  is  immediately  taken  up  into  the  tonsillar 
tissue,  and  produces  a  marked  diminution  in  pain,  while  if  the  abscess 
should  be  situated  in  the  interior  of  the  tonsillar  tissue,  the  contractile 


SURGICAL  DISEASES    OF    THE   PHARYNX  24I 

effect  of  the  solution  may  cause  an  earlier  spontaneous  evacuation 
through  the  lacunae. 

Of  the  other  infectious  inflammations  of  the  pharynx  may  be  men- 
tioned diphtheria,  of  which  the  surgical  aspects  will  be  considered 
under  diseases  of  the  larynx;  influenza,  typhoid  fever,  Vincent's  angina, 
erysipelas  and  scarlet  fever.  In  these  conditions  surgical  treatment  is 
not  necessary,  unless  pyogenic  complications  develop  under  which  cir- 
cumstances they  are  to  be  treated  along  the  lines  already  described. 

2.  CHRONIC  INFECTIONS 

Tuberculosis. — Of  the  chronic  infections,  primary  tuberculosis  of 
the  tonsils  is  chiefly  conspicuous  as  requiring  surgical  treatment.  This 
condition  is  usually  accompanied  by  a  similar  invasion  of  the  surgical 
lymph  nodes,  and  not  infrequently  involvement  of  the  adenoid.  Here 
a  thorough  excision  of  the  tonsils  and  adenoid  should  be  performed 
previous  to  any  operation  upon  the  lymph  nodes  of  the  neck,  in  order 
to  close  as  far  as  possible  this  portal  of  entry. 

Syphilis. — A  frequent  site  for  the  initial  lesion  is  the  tonsil,  which  has 
derived  a  certain  surgical  significance  from  the  practice  of  some  phy- 
sicians to  excise  the  organ  as  soon  as  the  disease  is  recognized.  This 
procedure  has  not,  however,  found  general  acceptance.  Secondary 
symptoms  do  not  require  surgical  consideration.  Of  the  tertiary 
lesions  the  gummatous  infiltrations  rarely  require  surgical  intervention, 
unless  in  the  later  stages  deformities  occur,  leading  to  interference  with 
articulation  or  swallowing.  Conditions  vary  here  to  such  an  extent 
that  no  general  rules  are  possible.  Most  frequently  one  encounters 
cicatricial  adhesion  between  the  soft  palate  and  posterior  pharyngeal 
wall,  leading  to  nasal  occlusion,  which  may  require  division,  with  an 
attempt  to  secure  an  epithelial  growth  over  the  cut  surfaces. 

3.  HYPERTROPHY   OF  THE   FAUCIAL  AND    PHARYNGEAL 
LYMPHOID  TISSUE 

From  birth  until  about  the  age  of  six,  a  rapid  increase  occurs  in  the 
number  and  size  of  the  follicles  of  the  lymphoid  tissue  in  the  pharynx, 
which  remain  essentially  unchanged  until  puberty,  when  a  diminution 
supervenes,  leading  to  a  progressive  shrinking  of  the  organ  as  old  age  is 
approached.  During  this  whole  period  the  lymphoid  tissue  experiences 
increase  in  size  in  response  to  various  stimulations.  Such  stimulations 
may  be  physiological,  as  in  the  enlargement  of  the  tonsils,  accompany- 
ing dentition,  or  pathological  and  dependent  upon  the  toxines  of  acute 
16 


242  REGIONAL   SURGERY 

and  chronic  infections.  In  certain  instances  the  tonsUs  fail  to  undergo 
their  normal  process  of  involution  and  remain  enlarged  into  middle  and 
old  age.  In  the  examination  of  the  tonsils,  we  have,  therefore,  first  to 
distinguish  between  those  hypertrophies  which  are  likely  to  be  transi- 
tory, and  those  in  which  no  material  change  can  be  expected. 

The  indications  for  the  removal  of  the  tonsils  are  (a)  harmful  en- 
largement, (b)  chronic  inflammation,  and  (c)  tendency  to  bacterial 
infection,  conditions  which  may  exist  singly  or  in  association. 

(a)  If  the  enlargement  is  sufl&cient  to  interfere  with  articulation, 
or  with  ventilation  of  the  Eustachian  tube,  a  partial  or  complete  re- 
moval of  the  organ  should  be  performed. 

(b)  Chronic  inflammation  of  the  tonsils  may  be  accompanied  by 
retention  of  debris  in  the  lacunae,  leading  to  a  variety  of  local  and  sys- 
temic disturbance,  such  as  bad  breath,  indigestion  and  cervical  adenitis. 

(c)  The  lymphoid  tissue  of  the  pharynx  and  fauces  may  exhibit  a 
tendency  to  bacterial  infections  which  may  be  acute  as  in  the  pyogenic 
inflammations  or  chronic  as  in  localized  tuberculosis. 

In  the  case  of  acute  infections  we  have  first  to  distinguish  between 
occasional  ones  arising  in  virtue  of  a  specially  virulent  t3^e  of  micro- 
organism and  those  infections  which  show  a  predisposition  to  recur- 
rence, dependent  upon  local  or  systemic  weakness  on  the  part  of  the 
host. 

Of  these  the  first  class  is  represented  most  typically  by  infections 
due  to  virulent  strains  of  streptococci,  as  in  scarlet  fever  and  the  septic 
sore  throat  from  infected  milk.  These  may  involve  both  the  tonsils, 
whether  or  not  previously  diseased,  and  the  follicles  of  the  adjacent 
mucous  membrane. 

Such  cases  do  not,  therefore,  enter  into  our  discussion  of  operative 
procedure. 

In  the  second  class  of  acute  infections,  namely  those  showing  tend- 
ency to  recurrence,  there  exists  a  primary  vulnerability  or  diseased 
condition  of  the  tonsils  most  frequently  represented  by  chronic  lacunar 
tonsillitis,  favoring  either  local  acute  inflammation,  as  acute  proHfera- 
tive  tonsillitis,  intrafolHcular  and  circumtonsillar  abscess,  or  permitting 
the  entrance  of  the  infecting  agent  into  the  general  system,  and  produc- 
ing a  variety  of  disturbances  such  as  endocarditis,  nephritis  and  arth- 
ritis. These  types  of  tonsils  call  always  for  complete  excision  when 
possible. 

The  removal  of  the  tonsils  may  be  partial  by  a  tonsillotomy  or  com- 
plete by  a  tonsillectomy.     On  the  continent  of  Europe  the  former  is 


SURGICAL   DISEASES    OF   THE  PHARYNX  243 

the  operation  of  choice,  particularly  in  children,  a  complete  removal 
being  reserved  for  conditions  of  general  systemic  infection,  arising 
through  the  tonsils.  In  England  and  America,  on  the  other  hand, 
tonsillectomy  is  more  frequently  advocated. 

In  choosing  the  method  of  operation  the  following  points  are  to  be 
considered: 

(a)  Trauma. 

(b)  Septic  complications. 

(c)  Hemorrhage. 

(d)  Alteration  of  the  anatomical  relationship  of  th^  parts  involved. 

(a)  Trauma. — With  reference  first  to  tonsillotomy,  the  ideal  opera- 
tion removes  as  much  of  the  tonsil  tissue  as  possible  without  injury 
to  the  pillars,  and  leaves  an  area  of  lymphoid  tissue  to  be  covered  in 
by  granulations.  This  procedure  is  accomphshed  most  t}T)ically  by 
the  various  amygdalotomes,  of  which  the  knife  moving  in  one  plane 
leaves  a  flat,  more  or  less  circular  wound,  represented  by  lymphoid 
tissue,  attached  to  the  capsule  of  the  organ.  Consequently,  the  area 
of  trauma  and  liability  to  subsequent  deformity  is  reduced  to  a  mini- 
mum. Unfortunately  in  the  case  of  imbedded  tonsils,  these  instru- 
ments are  of  Httle  use,  and  the  operator  is  obHged  to  employ  punches 
to  pass  between  the  pillars,  and  reach  the  lymphoid  tissue.  Although 
such  instruments  should  not  increase  the  risk  of  deformity,  yet  since  the 
area  of  a  hemisphere  is  greater  than  that  of  a  circle,  the  region  of  trauma 
is  unavoidably  extended,  with  consequent  increase  of  post-operative 
inflammation. 

Tonsillectomy  may  be  done  in  a  variety  of  ways,  distinguished  by 
the  manner  in  which  the  capsule  is  separated  from  its  surroundings. 
We  may  divide  the  methods  for  operation  into  two  classes,  namely, 
those  in  which  the  excision  is  performed  chiefly  by  the  use  of  relatively 
blunt  instruments,  and  those  in  which  the  excision  or  the  greater  por- 
tion of  it  is  accomphshed  by  sharp  knives  or  scissors.  Experience  has 
shown  that  the  amount  of  inflammatory  reaction  subsequent  to  the 
operation  depends  to  a  great  extent  upon  the  character  of  the  surface 
left.  In  general,  the  reaction  is  proportionate  to  the  extent  of  necrosis 
supervening  in  the  wound,  particularly  in  the  muscular  tissues. 

Since  the  necrosis  is  increased  by  overstretching  and  crushing  of 
the  parts,  the  manner  of  handling  the  instruments  is  of  primary  im- 
portance, and  two  operators  with  the  same  general  technique  may  achieve 
entirely  different  results  so  far  as  the  subsequent  discomfort  of  the 
patient  is  concerned.     For  many  surgeons  the  finger  operation  exposes 


244  REGIONAL    SURGERY 

the  patients  to  unnecessary  trauma.  While  it  is  true  that  the  use  of  a 
sharp  instrument  is  less  likely  to  be  followed  by  reaction  than  a  dull 
one,  3'et  on  the  other  hand,  the  cutting  of  vessels  by  a  sharp  knife  is 
more  likely  to  be  followed  by  troublesome  hemorrhage  than  if  these 
are  broken,  twisted  or  cut  with  a  dull  instrument.  I  have,  therefore, 
taken  as  the  ideal  tonsillectomy  those  methods  by  which  the  tonsil  is 
dissected  from  the  pillars  and  from  the  surrounding  tissues  by  such 
instruments  as  will  produce  a  minimum  of  trauma  down  to  the  point 
where  the  tonsillar  artery  enters,  this  spot  being  then  cut  through  by 
the  aid  of  a  dull  instrument  such  as  a  snare.  It  is,  of  course,  assumed 
that  the  vessels  in  the  pillars,  so  frequently  the  source  of  troublesome 
hemorrhage,  are  left  intact. 

In  the  Boston  hospitals,  the  following  method  has  been  generally 
adopted. 

After  a  hypodermic  injection  of  morphine  and  atropine,  propor- 
tionate to  the  patient's  age  (omitted  in  children),  ether,  introduced  by 
nitrous  oxide,  is  administered  to  a  point  immediately  beyond  the 
abolition  of  reflex  action  when  the  throat  is  touched.  It  is  important 
not  to  exceed  this  degree  of  anaesthesia  to  any  marked  extent,  as  we 
wish  the  patient's  control  over  coughing  and  swallowing  to  be  within 
prompt  reach  when  operative  bleeding  begins.  When  the  proper  stage 
of  anaesthesia  is  reached,  the  gag  is  introduced  on  the  right  side  by  a 
good  illumination  from  a  headhght,  the  patient  being  in  a  sitting  posi- 
tion, and  the  left  cheek  drawn  outward  to  the  left  by  the  etherizer. 
The  prepared  snare  is  passed  over  the  tonsil  forceps  and  allowed  to 
hang  free,  while  the  forceps  seize  the  right  tonsil  and  draw  it  slightly 
out  of  its  bed.  A  small  sharp  tenotomy  knife  performs  the  dissection 
from  above  downward,  the  cutting  edge  being  used  at  first,  and  often 
later,  as  occasion  requires,  the  back  of  the,  point,  in  order  to  avoid 
cutting  the  pillars  or  the  lymphoid  tissue  itself. 

The  dissection  proceeds  rapidly  down  to  the  point  where  the  ton- 
sillar artery  enters,  when  the  tonsil  is  lifted  upward,  and  a  horizontal 
cut  is  made,  delimiting  the  organ  from  the  lingual  lymphoid  tissue. 
The  snare,  which  in  the  meantime  has  been  hanging  free,  has  now  only 
to  be  slowly  closed  to  cover  the  region  of  the  artery  and  the  tonsil  comes 
away  in  the  forceps.  The  procedure  is  then  repeated  for  the  other 
side.  The  size  and  shape  of  the  knife  blade  is  of  the  first  importance, 
only  a  small  one,  which  can  be  easily  turned  in  the  hand,  and  made  to 
cut  as  described,  front  or  back,  meeting  the  requirements.  The  hypo- 
dermic injection  of  morphine  and  atropine  serves  the  purpose  of  keep- 


SURGICAL   DISEASES    OF   THE   PHARYNX  245 

ing  the  field  of  operation  dry,  and  diminishing  subsequent  pain.  The 
headhght  permits  accurate  manipulation  of  the  knife,  and  renders  one 
independent  of  the  varying  conditions  of  daylight  and  of  the  presence 
of  spectators. 

(6)  In  the  consideration  of  the  relation  of  sepsis  to  tonsil  opera- 
tions, an  increased  frequency  of  late  years  is  evident,  due  both  to  more 
radical  methods  of  operating,  and  to  the  fact  that  we  are  now  removing 
tonsils  more  often  than  before  for  conditions  which  in  themselves  favor 
the  occurrence  of  systemic  infection.  For  many  operators  it  is  true 
that  a  greater  amount  of  trauma  and  inflammatory  reaction  follows  their 
present  operations  of  tonsillectomy  than  occurred  after  their  earlier 
tonsillotomies. 

Since  greater  inflammatory  reaction  is  apt  to  follow  the  removal 
of  tonsils  which  are  in  themselves  essentially  septic  (a  reaction  which 
seems  often  unavoidable)  it  is  especially  necessary  to  operate  with  care, 
to  avoid  stretching  of  the  parts,  and  to  leave  the  wounded  surface  as 
clean  and  smooth  as  possible. 

(c)  Post-operative  hemorrhage  may  immediately  follow  the  opera- 
tion, but  occurs  most  frequently  several  hours  later.  Rarely  it  may 
appear  after  several  days.  If  it  proves  troublesome  directly  after  the 
operation,  it  may  often  be  treated  sufficiently  by  removing  the  clot 
from  between  the  pillars,  and  applying  pressure  for  a  few  minutes  to- 
the  bleeding  area  with  a  bit  of  styptic  cotton.  If  this  is  not  sufficient^ 
or  if  the  throat  is  intolerant,  approximation  of  the  pillars  may  be  done 
either  with  Michel's  clamps  or  by  passing  one  or  more  stitches  through 
the  pillars  by  means  of  a  curved  needle.  The  clamps  or  stitches  are 
applied  deeply  enough  to  approximate  the  pillars  close  to  the  bleeding 
vessel.  The  former  have  the  advantage  of  being  readily  applied  with- 
out general  anaesthesia,  and  are  easily  removed  in  24  hours. 

(d)  With  reference  to  the  conservation  of  the  anatomical  relation- 
ships of  the  parts  involved,  tonsillotomy  by  its  nature  should  produce 
no  gross  deformities,  and  yet  it  is  frequently  the  cause  of  a  serious 
result,  namely,  the  narrowing  or  occlusion  of  the  lacunar  orifices,  which 
are  left  in  the  stump  of  the  tonsil.  This  leads  to  the  accumulation 
of  detritus  in  the  crypts  with  resultant  absorption  of  decomposing 
material.  Since  tonsillectomy  produces  a  more  extensive  wound,  it  may, 
if  improperly  done,  produce  deformity.  The  pillars  may  be  cut  or 
torn  away,  or  they  may  become  fused,  or  a  stellate  cicatrix  may  occur 
with  resulting  puckering  and  retraction  of  the  parts.  Such  alterations 
of  structure  may  have  harmful  consequences  for  voice  production. 


246  REGIONAL   SURGERY 

4.  NEOPLASMS  OF  THE  PHARYNX 

Benign  Tiunors. — True  tumors  may  arise  from  the  ectoderm,  produc- 
ing papilloma  or  adenoma,  or  from  the  mesoderm,  gi\dng  fibroma,  lymph- 
oma, mj'xoma,  chondroma,  osteoma  and  angioma.  Of  these  the  most 
frequent  in  the  pharynx  is  papilloma,  characterized  by  the  presence 
of  numerous  fibrous  branches  covered  by  epithelium.  In  spite  of  its 
similarity  to  cancer,  on  account  of  its  tendency  to  active  atypical  pro- 
liferation, the  non-malignant  character  is  shown  by  the  fact  that  the 
epitheUum  covering  the  tumor  is  sharply  Hmited  below,  and  does  not 
at  any  place  penetrate  the  underlying  tissue.  The  growth  is  to  be 
distinguished  from  papillary  h3rpertrophy  found  at  times  in  the  tonsils, 
in  which  all  the  elements  of  the  mucous  membrane  participate. 
Adenoma  is  found  rarely  in  the  palate,  where  it  may  be  associated  with 
dilatation  of  lymphatics.  Fibromata  are  rare  in  the  pharyngeal  re- 
gions, although  of  frequent  occurrence  in  the  nasopharynx.  Lipo- 
mata  have  been  observed  upon  the  mucous  membrane  of  the  tonsils. 
They  consist  in  a  center  of  fat  tissue,  surrounded  by  more  or  less  abun- 
dant connective  tissue  in  the  peripheral  portions  and  are  covered  with 
the  mucous  membrane  of  the  parts.  They  are  apt  to  be  associated 
with  other  growths,  particularly  fibromata  and  myxomata.  The  fat 
tissue  in  these  growths  is  distinguished  from  normal  fat  tissue  from  the 
greater  size  of  its  cells  and  lobules.  It  may  be  associated  with  greater 
development  of  fibrous  tissue,  producing  a  fibrolipoma.  In  the 
tonsUs,  cystic  growths  may  arise  from  the  occlusion  of  a  lacuna  follow- 
ing inflammation  or  tonsillotomy,  and  may  give  rise  to  suspicion  of  a 
new  growth  until  incised.  The  walls  of  such  cysts  are  formed  of  flat- 
tened epithehum  and  the  contents  consist  of  fat  drops,  plates  of  choles- 
tearin,  exfoliated  epithelium,  and  leucocytes.  Tumors  of  the  lymphatics 
from  stasis  have  been  reported  from  the  pharynx. 

Malignant  Tumors. — Of  these  we  may  distinguish  two  chief  tj^es, 
according  as  they  arise  from  the  ectoderm  (or  entoderm)  or  from  the 
mesoderm,  the  former  being  represented  by  carcinoma,  the  second  by 
sarcoma.  In  the  pharynx,  carcinoma  occurs  with  relative  frequency, 
particularly  in  the  region  of  the  tonsils.  It  may  also  occur  upon  the 
tip  of  the  uvula  as  a  primary  growth  in  this  situation.  The  only  treat- 
ment is  surgical  removal,  if  possible,  together  with  the  lymph  nodes 
of  the  affected  side. 

Sarcoma. — These  tumors  consist  to  a  greater  or  less  extent  of  im- 
mature forms  of  connective  tissue,  produced  through  proliferation  of 
cells  of  mesodermal  nature.     The  growths  may  assume  clinically  either 


SURGICAL  DISEASES    OF   THE   PHARYNX  247 

the  form  of  a  sarcoma  or  of  a  malignant  lymphoma.  The  majority  of 
writers  now  consider  that  no  essential  resemblance  exists  between  maUg- 
nant  lymphoma  and  Hodgkin's  disease,  and  that  often  no  sharp  line  of 
demarcation  can  be  found  to  separate  these  conditions  from  sarcoma 
and  lymphosarcoma.  For  clinical  purposes  it  is  convenient  to  separate 
the  cases  into  the  typical  forms,  and  we  may  say  that  by  the  term 
pseudo-leucemia  (Hodgkin's  disease,  mahgnant  lymphoma)  is  denoted 
a  condition  characterized  clinically  by  progressive  enlargement  of  the 
various  organs  of  the  body  in  which  lymphadenoid  tissue  occurs,  ex- 
tending by  the  way  of  the  lymph  channels  from  one  group  of  glands  or 
nodes  to  those  in  contiguity,  and  exhibiting  histologically  a  proliferation 
of  the  reticulum  and  marked  increase  of  fibrous  tissue,  associated  with 
numerous  lymphocytes.  By  sarcoma  of  lymphadenoid  tissue  (synonym, 
lymphosarcoma)  is  denoted  a  malignant  enlargement  of  such  tissue, 
exhibiting  clinically  a  tendency  to  invade  the  organs  in  the  immediate 
vicinity,  and  characterized  histologically  by  a  replacement  of  the 
normal  follicular  structure  by  numerous  round  cells  with  a  small  amount 
of  endothelial  reticulum. 

The  prognosis  in  these  conditions  is  unfavorable.  The  X-ray  has 
been  reported  to  be  of  service  in  some  instances  of  lymphoma. 

In  rare  instances  spontaneous  recovery  has  been  noted.  In  one  case 
of  lymphosarcoma  of  the  author's,  complete  recovery  followed  the  use  of 
staphylococcus  vaccines,  in  connection  with  the  hypodermic  adminis- 
tration of  turpentine,  the  latter  being  for  the  purpose  of  producing  sup- 
puration below  the  skin.  The  use  of  the  staphylococcus  vaccines  has 
been  found  helpful  also  in  Hodgkin's  disease  with  localization  in  the 
neck  and  fauces. 

Coley  has  observed  marked  improvement  and  some  apparent  cures 
in  sarcoma  from  the  use  of  vaccines  of  streptococcus  pyogenes  and 
bacillus  prodigiosus. 

Malignant  growths  of  the  faucial  pillars,  uvula  and  tonsils,  if  recog- 
nized sufficiently  early,  while  still  sharply  circumscribed,  may  be  com- 
pletely excised  through  the  mouth.  In  the  case  of  the  tonsils  this 
procedure  is  seldom  sufficient  as  the  cervical  lymph  nodes  are  involved 
so  promptly  that  their  simultaneous  excision  is  essential.  Under  these 
circumstances  we  may  have  recourse  to  subhyoid  pharyngotomy,  or 
to  lateral  pharyngotomy. 

Subhyoid  Pharyngotomy. — A  transverse  incision  is  made  at  the 
level  of  the  hyoid  from  one  horn  to  the  other.  The  sternohyoid,  thyroid 
and  omohyoid  muscles  are  cut  through  as  close  as  possible  to  their  at- 


248  REGIONAL    SURGERY 

tachments  to  the  hyoid,  in  order  to  avoid  the  superior  laryngeal  nerve. 
The  thyroid  membrane  is  thus  exposed  and  is  incised  along  its  attach- 
ment to  the  hyoid  bone.  With  the  finger,  the  operator  can  now  push 
the  glosso-epiglottic  fossa  forward  and  downward,  exposing  the  pharynx 
freely,  and  permitting  the  removal  of  the  diseased  portions  of  pharynx 
and  tonsils.  Kocher  recommends  the  thermocautery  in  preference 
to  scissors,  as  being  less  likely  to  be  followed  by  metastases.  In  closing 
the  wound  it  is  advisable  to  leave  a  tampon  of  iodoform  gauze,  so  as  to 
extend  as  far  as  the  deep  sutures.  A  tracheotomy  may  be  necessary 
on  account  of  the  secondary  oedema  of  the  glottis. 

Lateral  pharyngotomy  is  recommended  for  removal  of  extensive 
growths  of  the  tonsils  and  pillars.  After  preliminary  tracheotomy, 
an  incision  is  made  from  the  mastoid  process  to  the  middle  of  the  hyoid 
bone.  The  auricularis  magnus  nerve  and  the  jugular  vein  are  cut  if 
necessary,  the  anterior  facial,  jugular  vein  and  external  maxillary  artery 
are  tied  and  cut;  the  submaxillary  gland  extirpated  and  the  lingual 
pharyngeal  and  palatine  arteries  tied  at  their  point  of  origin.  It  is 
thus  possible  to  draw  the  large  vessels  of  the  neck  backward  and  the 
hypoglossal  nerve  upward.  The  incision  now  proceeds  along  the  inner 
aspect  of  jaw,  and  the  pterygoid  muscle  toward  the  pharyngeal  mucous 
membrane,  leaving,  however,  intact  as  far  as  possible  the  nerves  sup- 
plying the  muscles  which  move  the  hyoid  and  larynx.  This  is  best  done 
by  cutting  the  digastric  and  stylohyoid  at  the  hyoid  attachments,  and 
the  styloglossus  near  the  tongue.  Finally  after  the  separation  of  the 
stylopharyngeus,  the  hyoglossus  and  mylohyoid  from  their  hyoid  at- 
tachment, the  external  pharyngeal  wall  lies  exposed.  The  growth  can 
then  be  removed  together  with  whatever  glands  may  be  involved. 


SECTION  XV 

NOSE 
By 

LEE  M.  KURD,  M.  D.,  F.  A.  C.  S. 

New  York,  N.  Y. 

EXTERNAL  NASAL  DEFORMITIES 

Aquiline  or  Hump  Nose. — Disfiguring  prominence  of  the  nasal  bones 
can  be  removed  internally  or  externally.  An  internal  operation  under 
general  anaesthesia  is  preferable.  For  this  procedure,  douche  the  nose 
with'normal  sahne  solution,  then  introduce  the  sharp  end  of  the  author's 
septal  elevator  (Fig.  125)  into  either  nostril  until  it  impinges  upon  the 
inferior  edge  of  the  nasal  bone  of  that  side,  engaging  the  tissues  and 
working  the  elevator  through  until  it  is  between  the  periosteum  and  the 
nasal  bone.  Now  reverse  the  elevator,  and  continue  the  dissection 
with  the  dull  end  (which  is  made  of  copper  and  which  can  be  bent  to 
any  curve  necessary  to  fit  the  case),  until  all  the  periosteum  is  free  from 
the  hump,  then  introduce  the  author's  draw  chisel  (Fig.  1 20)  and  pare  the 


ncsBsssx^ 


0 


Fig.  120. — This  chisel  fits  the  universal  handle  of  Myles'  draw  chisels. 

hump  down  slightly  lower  than  the  requirements,  as  there  will  be  some 
thickening  from  callous  and  fibrous  tissue  produced.  Douche  the 
cavity  with  normal  saUne  solution  to  remove  the  debris,  and  mould 
to  the  nose  a  pad  of  dental  gutta-percha,  softened  in  hot  water;  after- 
ward harden  the  mould  in  cold  water.  This  pad  will  prevent  hemor- 
rhage and  is  held  in  place  with  strips  of  adhesive  plaster  placed  across 
the  face. 

A  possibility  of  sepsis,  because  of  the  difiiculties  of  sterilizing  the 
interior  of  the  nose,  is  the  one  objection  to  this  procedure.  In  five 
cases  I  have  had  one  infection,  causing  a  thickening  which  was  as  bad 
as  the  original  deformity. 

External  Method. — An  incision,  a  little  longer  than  the  prominence 
to  be  reduced,  is  made  through  the  skin  and  periosteum,  vertically  along 
the  angle  of  the  anterior  and  lateral  planes  of  the  nose.     The  periosteum 

249 


250 


REGIONAL   SURGERY 


is  'elevated,  the  hump  is  removed  with  sharp  chisels  and  the  flaps 
coapted  with  adhesive  plaster.  This  procedure  leaves  a  scar  which  is 
hardly  noticeable. 

Displacement  of  the  Nose,  Laterally. — This  deformity,  when  it 
involves  the  nasal  bones,  is  usually  the  result  of  violence  and  is  rarely 
a  congenital  condition.  Where  the  nasal  bones  are  displaced  to  one 
side,^the  bone  on  the  side  of  the  displacement  usually  over-rides  the 
superior  maxillary  bone  and  the  opposite  bone  is  depressed.  In  cor- 
recting this  deformity,  the  object  is  to  freely  loosen  the  bones,  to 
replace  them,  and  then  to  hold  them  firmly  until  united,  for  doing  which, 
the  heavy  Asch  forceps  is  applied  to  the  nasal  bone,  one  blade  being 


Fig.  121. — Hard  rubber  intranasal  splints  used  in  fractures. 

introduced  into  the  nose  and  the  external  blade  being  covered  with 
rubber  tubing  to  prevent  injury  to  the  skin.  The  nasal  bone  is  now 
grasped  firmly  and  rotated  until  free  from  its  attachments.  The  same 
is  done  to  the  opposite  nasal  bone;  then  the  septum  is  grasped  with  the 
forceps  and  fractured  just  under  the  nasal  bones.  The  bones  should 
now  be  sufficiently  pliable  to  allow  of  being  placed  in  position  and  to 
remain  so  without  support.  In  some  cases,  however,  the  depressed 
bones  need  some  support  in  the  nose  to  hold  them  in  place.  A  small 
quantity  of  gauze,  packed  in  the  nose  under  the  nasal  bone  will  usually 
give  the  necessary  aid.  Sometimes  a  stronger  support  than  this  is 
required;  then  a  hard  rubber  nasal  splint  (Fig.  121)  can  be  used  in  one  or 
both  of  the  nostrUs  for  a  few  days  until  the  bones  become  fixed  in  their 
new  positions.  A  lateral  displacement  of  the  tip  of  the  nose  is  due  to 
the  distortion  of  the  septal  cartUage.  Correcting  the  septal  deviation 
by  a  submucous  resection  will  tend  to  bring  the  nasal  tip  into  the 
median  line. 

Saddle  or  Deformed  Nose  (Fig.  122). — This  condition  is  usually 
caused  by  syphiUs,  atrophic  rhinitis,  abscess  of  the  septum,  cretinism  and 
occasionally  by  trauma,  and  can  be  easily  corrected  by  injecting  paraffin 
(Fig.  123),  though  not  without  danger  as  part  of  the  paraffin  may  escape 


NOSE 


25^ 


into  the  blood-stream  and  cause  emboli  in  the  lungs,  coronary  arteries 
or  the  central  artery  of  the  retina  (several  cases  of  unilateral  blindness 
have  been  reported). 


Fig.  122. — Saddle  nose  (traumaticj. 


Fig.  123.' 


-Same  after  paraffin  has  been 
injected. 


The  Technique  of  Paraffin  Injection. — Perfect  asepsis  is  necessary. 
Special  paraffin,  melting  at  iio°F.  (cold  in  its  solid  state),  is  injected 
by  means  of  a  special  syringe  (Fig.  1 24) .  The  needle  is  introduced  either 
at  the  root  of  the  nose  or  at  the  tip  and  pushed  along  under  the  skin 
until  its  point  is  at  the  further  end  of  the  depression.  At  this  point  an 
assistant,  standing  behind  the  patient,  puts  pressure  with  his  thumbs 
on  the  sides  of  the  nose  to  prevent  extravasation  of  the  paraffin  toward 


-s^^a^ 


Fig.  124. — Paraffin  syringe.     {Broekaerl.) 

the  cheeks.     The  operator  now  slowly  injects,  at  the  same  time  gradu 
ally  withdrawing  the  needle  and  injecting  a  little  more  than  is  necessary 
as  eventually  there  will  be  some  shrinkage.     Another  precaution  is  to 
cease  injecting  as  soon  as  the  pressure  of  the  paraffin  causes  blanching 


252  REGIONAL   SURGERY 

of  the  skin,  otherwise  the  pressure  will  cause  a  slough.     It  is  better  to 
inject  more  parafl6n  later. 

To  build  up  the  nose  from  depressions  in  which  the  nasal  bones  have 
been  fractured  and  have  over-ridden  the  nasal  processes  of  the  superior 
maxillary,  it  is  necessary  to  refracture  or  loosen  the  nasal  bone  or  frag- 
ments freely  and  to  bring  them  back  into  their  original  place,  fixing 
them  until  they  unite.  Sometimes,  as  in  a  recent  fracture,  this  can  be 
accomplished  by  the  use  of  a  small  amount  of  gauze  packed  in  the  an- 
terior part  of  the  nose  or  by  special  splints,  as  illustrated,  which  per- 
mit of  nasal  breathing  while  the  repair  is  taking  place. 

Depressions  resulting  from  loss  of  bone  or  cartilage,  especially  of  bone, 
require  replacement  of  bone  which  can  be  done  best  by  resecting  a  piece 
of  the  patient's  ninth  rib,  about  2  in.  long  (Carter's  method)  and  trim- 
ming this  piece  of  bone  down  till  it  fits  the  requirements  of  the  nose. 
The  nose  is  prepared  for  the  reception  of  the  piece  of  bone  from  the  rib 
by  making  a  transverse  incision,  }4  in.  long,  between  the  eyebrows. 
Through  this  incision,  the  tissue  down  over  the  bridge  to  the  nasal  tip 
being  loosened  with  a  narrow  knife,  the  piece  of  well-trimmed  bone  is 
then  slipped  in,  and  the  incision  is  closed. 

Deformities  in  which  a  portion  of  the  soft  tissues  as  well  as  the  bone 
and  cartilage  have  been  destroyed,  require  the  transplantation  of  tissue 
from  some  part  of  the  body.  Where  soft  tissue  only  is  required,  a 
flap  can  be  cut  from  the  forehead  down  to  the  periosteum,  with  the 
base  of  the  flap  toward  the  root  of  the  nose.  Make  the  flap  at  least  3^ 
in.  wider  and  considerably  longer  than  necessary  to  fill  up  the  gap  to 
allow  for  shrinkage.  The  required  shape  of  this  flap  from  the  forehead 
is  best  cut  by  outlining  a  pattern  of  the  part  of  the  nose  to  be  filled  in, 
and  then  reversing  this  pattern  for  making  the  forehead  flap.  When 
the  flap  is  turned  down  to  be  sutured  in  the  nasal  defect,  the  pedicle 
should  not  be  severed  for  ten  days;  then  it  should  be  divided  the  nasal 
portion  being  sutured  into  the  upper  part  of  the  defect  and  the  balance 
replaced  in  the  forehead  by  opening  the  old  incision  sufficiently.  Where 
bone  and  soft  tissue  are  required,  a  finger  can  be  transplanted,  or  better 
still,  a  section  of  a  rib  can  be  transplanted  under  the  skin  of  the  arm,  re- 
maining there  until  it  becomes  a  part  of  its  new  position.  A  flap,  in- 
cluding this  piece  of  bone,  is  then  made  and  the  arm  is  brought  up  to 
the  nose  and  held  there  by  means  of  a  plaster  cast,  the  edges  of  the  flap 
being  sutured  to  the  nasal  defect,  and  the  arm  being  held  in  place  until 
the  union  is  completed;  then  the  flat  pedicle  is  severed  and  sutured  to 
the  base  of  the  nasal  defect. 


NOSE  253 

Bulbous  Nose. — Where  the  tip  of  the  nose  is  abnormally  large,  the 
tip  can  be  made  narrower  by  removing  portions  of  the  superior  and  in- 
ferior lateral  cartilages  from  within  the  nose.  Small,  right-angle, 
aural  knives,  introduced  through  the  nasal  mucosa  and  cartilage,  will 
outline  the  amount  of  cartilage  to  be  removed;  usually  an  elliptical 
excision  is  sufficient  to  reduce  the  size. 

Recent  Fracture. — In  recent  fracture  of  the  nasal  bones,  anaes- 
thetize the  nasal  mucous  membrane;  introduce  some  straight  instrument 
like  a  periosteal  elevator  into  the  nose,  lift  the  bones  into  place  and 
pack  antiseptic  gauze  into  one  or  both  sides  of  the  nose,  as  need 
be,  to  hold  the  bones  in  place,  the  small  amount  of  gauze  is  pushed 
up  anteriorly  under  the  nasal  bones.  The  fractured  bones  remain  in 
position  without  packing  after  48  hours. 

Long  or  Parrot  Nose. — This  can  be  corrected  by  simply  removing 
a  V-shaped  piece  from  the  cartilaginous  portion  just  below  the  nasal  bone 
and  pulling  the  tip  up  with  sutures  and  adhesive  plaster. 

Anaesthesia. — In  all  operations  upon  the  nose,  the  most  important 
preliminary,  after  the  patient's  health  has  been  considered,  is  the  anaes- 
thesia. All  the  intranasal  operations  can  and  should  be  performed  under 
a  local  anaesthesia,  because  the  operative  field  is  more  bloodless.  In  the 
case  of  nervous  and  apprehensive  patients,  for  several  years  I  have 
pursued  the  plan  of  giving  morphine,  gr.  }-i  and  hyoscine,  gr.  Koo? 
60  minutes  before  the  time  of  the  operation,  and  if  necessary,  to  quiet 
the  patient,  I  repeat  the  dose  in  half  an  hour.  The  nose  can  be 
easily  anaesthetized  with  a  10  per  cent,  solution  of  cocaine,  or  one  of  its 
substitutes.  Personally,  I  prefer  alypin,  10  per  cent,  solution,  on 
account  of  its  less  toxic  quaUties.  To  both  solutions,  there  should  be 
added  five  drops  of  adrenalin  to  the  dram  of  the  anaesthetic,  which 
solutions  are  easily  applied  to  all  of  the  ramifications  of  the  nasal  cavity 
by  the  compressed  air  spray,  the  patient's  head  being  bent  well  forward 
while  spraying  so  that  the  excess  of  the  solution  may  drain  out  of  the 
anterior  nares  rather  than  run  backward  into  the  throat  where  it  causes 
considerable  annoyance.  Use  three  applications  of  the  spray  with  an 
interval  of  a  few  minutes  between  each  one,  which  will  allow  the  first 
application  time  to  contract  the  mucous  membrane  and  the  subsequent 
applications  will  act  on  the  deeper  parts.  After  an  interval  of  10 
minutes  the  nose  will  be  found  to  be  completely  anaesthetized  and  the 
patient  quite  indifferent  after  the  preUminary  administration  of  the 
morphine  and  hyoscine.  If  the  operative  field  includes  any  of  the  nasal 
sinuses,  a  solution  of  alypin  and  adrenalin  should  be  injected  by  means 
of  a  cannula. 


254 


REGIONAL    SURGERY 

DEFORMITIES,  INTERNAL 


Deviation  of  the  Septum.- — De^dation  of  the  septum,  which  is  some- 
times traumatic,  is  usually  due  to  unequal  development  of  the  bony 
frame  of  the  face.  The  traumatic  conditions  can  be  easily  distinguished 
by  the  acute  angles  in  the  septum,  and  they  rarely  extend  beyond  the 
quadrilateral  cartilage.     The  deviations  take  on  many  forms,  the  most 


SillilllillilM^ 


Fig.  125. — Elevator,  one  end  of  copper,  which  can  be  bent  readily  to  any  desired  curve. 

frequent  being  along  some  one  or  more  of  the  articulations  of  the  vomer, 
perpendicular  ethmoidal  plate  and  quadrilateral  cartilage.  Nearly 
every  nasal  septum  is  more  or  less  out  of  the  median  line,  and  may  be 
considerably  deviated  without  giving  symptoms.  Impaired  drainage 
of  the  nose  or  accessory  sinuses  and  poor  ventilation  of  the  nose  are 
sufficient  causes  for  surgical  interference,  the  impaired  drainage  causing 
infection   of    the    accessory   sinuses,   recurrent   coryzas,   and    chronic 


Fig.  126. — Heavy  forceps  for  resection  of  the.  nasal  septum. 

rhinitis,  while  the  obstruction  to  the  air  current  often  induces  catarrhal 
conditions  of  the  Eustachian  tube  and  middle  ear,  and  may  also  cause 
more  or  less  change  in  the  larynx,  trachea,  and  bronchi.  Pressure  of  the 
deviated  septum  against  the  outer  nasal  wall  is  occasionally  accountable 
for  indefinite  sensations  in  the  orbit  and  for  eye-fatigue,  and  may  also 
cause  neuralgia  and  headache.  The  deviation  should  not  be  corrected 
during  an  attack  of  acute  coryza,  acute  otitis  media  or  diabetes,  but  in 
the  case  of  an  acutely  infected  sinus,  an  operation  might  be  considered, 
under  stress  for  drainage. 


NOSE 


255 


Technique. — The  preliminary  anaesthesia  as  previously  described,  is 
advised.  A  few  special  instruments  are  required,  namely,  elevator 
(Fig.  125),  two  or  three  special  forceps 
(Figs.  126,  127,  128),  a  speculum  (Fig. 
129),  a  right-angle  knife,  and  a  curette. 

For  doing  the  resection,  a  curved  in- 
cision is  made  down  to  the  cartilage, 
always  on  the  convex  side  and  in  front  of 
the  deviation,  where  the  septum  is  in  the 
median  Hne;  then  the  muco-periosteum  is 
elevated  over  the  convex  surface  as  far 
as  the  deviation  (Figs.  130,  131,  132) 
extends.  With  a  curette,  starting  well  up 
just  posteriorly  to  the  incision,  a  strip  of 
cartilage  is  removed  down  to  the  floor. 
This  is  easily  and  safely  done  by  holding 
the  curette  like  a  pen  and  slightly  rotat- 
ing it  on  its  long  axis  as  the  curette  engages  the  cartilage. 
The  muco-periosteum  is  elevated  on  the  concave  side  through 
the  window  in  the  cartilage.  The  membrane  is  elevated  easiest 
in  the  superior  portion  which  should  be  done  first,  then  from 
this   space,   starting   well   posteriorly,   elevate   the   membrane  down- 


FiG.  127. — Down-cutting  forceps  for 
septal  resection. 


Fig.  128. — Killian's  duck-bill  forceps  for  resection  nasal  septum. 

ward  and  forward.  It  will  be  found  that  the  lower  part  of  the 
membrane  can  be  detached  without  fear  of  perforations,  if  done  from 
behind  forward.  In  elevating  the  concave  membrane,  it  is  best  to 
watch  the  progress  of  the  elevator  under  the  membrane  by  looking  into 
the  nares  of  the  concave  side.     The  deviated  cartilage  and  bone  are  now 


256 


REGIONAL   SURGERY 


ready  to  be  removed  with  the  large  biting  forceps,  and  the  work  is 
greatly  facihtated  by  using  the  special  septal  speculum  which  keeps 
the  two  membranes  well  apart,  and  permits  a  better  view  of  the  opera- 
tive field.  The  cartilage  and 
bone  should  be  entirely  re- 
moved wherever  they  are  out 
ofthe  median  hne,  as  partial 


Fig.  129. — Speculum  vrith  short 
and  long  blade,  used  to  retract  the 
septal  membrane. 


Fig.  130. — The  nasal  septum.  A,  Curved 
incision;  B,  Quadrilateral  cartilage;  C,  the  nasal 
bone;  D,  perpendicular  plate  of  ethmoid;  -E,  the 


removal  will  later  cause  a  vibration  of  the  septal  membrane  during 
respiration  which  is  annoying  to  the  patient.  With  the  cartilage  and 
bones  removed,  the  membranes  fall  into  apposition,  and  for  a  time 
packing  is  necessary  to  hold  them  in  place.     The  method  is  to  pack 


Fig.  131. — The  shaded  portion  represents  the  portion  of  the  septum  removed.     A  shows 
the  down  cutting  forceps  engaging  the  anterior  nasal  spine. 

plain  gauze  inside  a  rubber  condom  sufl&ciently  tight  to  keep  the 
two  membranes  together,  which  packing  is  removed  after  24  hours; 
first  remove  the  gauze,  then  the  rubber  bag  will  collapse. 

Hyperlrophied  middle  turbinates  that  obstruct  drainage  of   the  ac- 


NOSE 


'S7 


cessory  sinuses  or  cause  stuffiness  and  pressure  across  the  nasal  bridge 
should  be  removed  (Figs.  133,  134,  135,  136),  which  is  easily  done  with 
nasal  scissors  (Beckmann's)  and  a  snare.     Introduce  the  scissors,  one 


Fig.  132. — A,A'  shows  the  incision  held  open  by  the  long  blade  of  the  speculum.  C,C', 
Dotted  enclosure,  indicating  the  amount  of  the  septum  removed.  B,B'  shows  the  down- 
cutting  forceps. 

blade  into  the  olfactory  j&ssure  and  the  other  blade  at  the  anterior 
attachment  of  the  turbinate  with  the  outer  nasal  wall,  pushing  the 
blades  upward  and  backward  as  far  as  they  will  go  without  resistance, 


Fig.  133. — First  cut  with  scissors,  upward 
and  backward. 


Fig.  134. — Successive  scissor  cuts. 


about  3-4  in.  Divide  the  tissue,  then  depress  the  scissors'  handles  so 
that  the  blades  will  fracture  the  middle  turbinate  along  its  attachment. 
Carry  the  blades  of  the  scissors  in  a  backward  direction,  severing  more 
of  the  attachment,  and  again  depress  and  so  on  with  small  cuts  until  the 


258 


REGIONAL   SURGERY 


turbinate  is  hanging  only  by  a  small  posterior  portion.  Now  pass  the 
snare  loop  around  the  hanging  portion  with  the  cannula  above  until  the 
loop  engages  the  portion  remaining  attached,  and  snare  off. 

Enlargement  of  the  inferior  turbinate  may  be  divided  into  the  hyper- 
plastic and  the  hypertrophied  forms. 


Fig.  135. — Removal  of  the  pedicle  with  the  snare. 

The  hyperplastic  variety  is  frequently  secondary  to  some  local 
derangement,  such  as  the  septal  deviation,  or  to  a  general  condition, 
such  as  an  excess  of  uric  acid,  the  alcoholic  habit  or  the  unstable  vaso- 
motor conditions.     Aside  from  correcting  any  primary  local  cause,  the 


Fig.  136. — Beckmann's  scissors  for  the  removal  of  the  middle  turbinate  bone. 


most  successful  local  treatment  is  the  use  of  the  electric  cautery  at 
cherry-red  heat  About  three  hnear  cauterizations  are  sufficient  (Fig. 
137).  The  cautery  blade  is  passed  to  the  posterior  end  of  the  turbinate, 
and  with  the  current  now  turned  on,  it  is  drawn  slowly  and  smoothly 
forward,  first  along  the  inferior  border,  then  along  the  middle,  and  again 
near  its  upper  portion.  Avoid  using  the  cautery  too  hot  (cherry  red). 
A  slow  and  steady  motion  while  burning  will  seal  up  the  vessels  and 


NOSE 


259 


leave  a  dry  field.     Lack  of  these  precautions  may  lead  to  troublesome 
hemorrhage,  requiring  packing. 

The  hypertrophied  variety  feels  firm  to  the  probe,  will  not  diminish 
materially  in  size  under  cocaine  and  adrenal  in  solution,  and  is  most 


Fig.  137. — Lines  for  applying  electric 
cautery. 


Fig. 


138. — Line  of  incision  in  partial  in- 
ferior turbinectomy. 


advantageously  corrected  by  removing  all  portions  that  obstruct  the 
nose,  from  before  backward,  with  heavy  scissors  (Fig.  138)  or  von 
Struychen's  forceps  (Fig.  139),  which  instrument  meets  these  conditions 


Fig.  139. — von  Struychen's  forceps. 


best.  After  the  removal  of  all  the  obstructive  portions,  the  nostril 
should  be  firmly  packed  with  antiseptic  gauze.  First  place  a  strip  of 
gutta-percha  over  the  denuded  area  to  prevent  the  adherence  of  the 
gauze,  thus  avoiding  severe  hemorrhage  at  the  time  of  removal. 


26o  REGIONAL   SURGERY 

Enlargement  of  the  posterior  portion  of  the  inferior  turbinate  fre- 
quently occurs,  and  is  usually  secondary  to  some  obstruction  of  the 
nose  such  as  a  de\aated  septum,  the  enlargements  generally  subsiding 
after  correcting  the  primary  cause.  When  they  fail  to  subside,  they 
may  be  snared  off  by  engaging  the  posterior  portion  of  the  inferior 
turbinate  with  a  wire  loop,  bent  at  an  angle  with  the  snare  cannula, 
but  this  is  rarely  necessary. 

Perforation  of  the  septum  rarely  causes  trouble.  It  is  due  to  syphilis, 
typhoid  and  other  infections.  It  may  also  be  produced  surgically,  and 
sometimes  by  the  persistent  use  of  the  patient's  fingernail,  attempting 
to  remove  an  obstruction  or  crust  on  the  cartilaginous  septum.  If  the 
crust  is  sufficient  to  cause  annoyance,  it  can  usually  be  remedied  by  re- 
ducing the  edge  of  the  perforation  through  removal  of  the  cartilage  and 
bone  between  the  membranes  for  one-fourth  of  an  inch.  The  various 
methods  of  using  a  flap  of  the  septum  to  cover  the  opening  usually 
fail. 

AtresicB  and  adhesions  in  the  nasal  cavities,  due  to  syphilis  or  care- 
less use  of  caustics,  are  reheved  by  the  general  principle  of  dividing  the 
bands  and  interposing  some  non-irritating  material,  sach  as  gutta- 
percha, until  the  surfaces  heal. 

INFECTIONS 

Furunculosis  of  the  nasal  vestibule  is  an  infection  of  the  hair  follicles, 
and  is  generally  associated  with  intestinal  fermentation  or  compHcat- 
ing  purulent  processes  in  the  nose.  The  symptoms  are  swelling,  redness 
and  tenderness  of  the  nasal  tip.  Incision  of  the 
abscess  within  the  vestibule  will  promptly  relieve  any 
particular  furuncle,  but  as  it  is  quite  liable  to  recur, 
the  condition  of  the  general  health  often  needs  con- 
sideration. 

Acute  abscess  of  the  nasal  septum  is  usually  the 
result  of  trauma,  erysipelas,  or  an  infective  fever  such 
ing'o^f  the'^ptum  ^^  typhoid,  scarlet,  etc.  (Fig.  140). 
from  hematoma  or  Symptoms  are  the  history  of  trauma  with  evidence 
of  external  violence,  pain  and  tenderness  of  the  nasal 
tip,  nasal  obstruction,  headaches  and  general  malaise,  with  at  times 
rise  of  temperature.  On  inspection,  the  septum  is  bulging,  filling  the 
entire  nasal  cavity  in  front  on  both  sides,  the  eyes  may  be  congested, 
and  there  may  be  swelling  of  the  under  lid  and  of  the  entire  face. 
Diagnosis  is  easy,  as  the  history  of  short  duration  with  the  swollen 


NOSE  261 

septum  is  rarely  due  to  anything  else,  and  if  incised  early,  more  blood 
than  pus  will  be  found.  I  have  never  seen  a  simple,  chronic  abscess  of 
the  septum,  and  I  believe  them  to  be  very  rare. 

Prognosis  is  good  regarding  the  extension  and  the  development  of 
the  general  sepsis,  but  poor  from  a  cosmetic  point  of  view.  There  will 
be  a  depression  in  the  nasal  profile  just  below  the  nasal  bones  from  the 
accompanying  chondritis  if  not  promptly  and  intelligently  treated. 

Treatment. — After  anaesthetizing  both  sides  of  the  septum,  make  a 
liberal  incision  in  each  side,  avoiding  later  perforations  by  not  making 
these  ncisions  opposite  each  other;  then  through  these  incisions  in- 
spect the  cartilage,  removing  all  that  appears  infected,  the  prompt  re- 
moval of  which  prevents  extension  of  the  chondritis  and  the  possible 
resulting  deformities.  As  the  hematoma  from  trauma  quite  regularly 
breaks  down,  the  earlier  it  is  opened  the  better.  Keep  the  septal  flaps 
apart  with  iodoform  gauze  and  treat  as  an  open  wound. 

Diphtheria. — Primary  diphtheria  of  the  nose  may  be  acute  or 
chronic.  The  acute  cases  have  little  or  no  febrile  symptoms.  The  nose 
secretes  a  foul  serous  discharge  which  is  sometimes  sanguineous,  while 
the  nasal  orifice  is  inflamed  and  there  is  occasionally  epistaxis.  The 
membrane  may  be  located  at  any  place  within  the  nose,  generally  cover- 
ing most  of  the  mucosa  and  rarely  extending  from  the  nose  to  the  upper 
lip,  or  backward  to  the  throat.  It  is  gray  in  color  and  sometimes  stained 
brown  with  blood.  It  is  quite  adherent,  and  its  removal  causes  bleed- 
ing. When  the  infection  remains  nearly  a  pure  Klebs-Loeffler,  the 
symptoms  may  run  a  benign  course  except  in  the  case  of  infants,  who 
seem  to  bear  this  nasal  infection  poorly.  In  cases  in  which  there  is  a 
mixed  infection  of  streptococci  and  staphylococci,  the  course  of  the 
disease  is  severe.  The  average  case  that  the  rhinologist  sees  is  a 
diphtheria  carrier,  and  the  patient  seems  immune  to  extension  of  the 
infect'on  which  runs  a  subacute  or  chronic  course  without  general 
symptoms. 

Diagnosis. — Nasal  diphtheria  may  be  confounded  with  membranous 
rhinitis,  but  in  the  latter  the  membrane  can  be  easily  detached  without 
hemorrhage,  and  there  is  little  or  no  odor  to  the  discharge.  The  find- 
ings of  a  bacteriological  culture  will  clearly  decide  the  question. 

Treatment. — Antitoxin  is  indicated,  although  it  does  not  act  as 
promptly  as  in  the  case  of  faucial  diphtheria.  Sahne  douches  should  be 
employed  locally.     Antiseptic  douches  seem  to  prolong  the  infection. 

Epidemic  Influenza. — This  infection  frequently  involves  the  nose 
and  nasal  accessory  sinuses,  the  attack  often  beginning  as  an  acute 


262  REGIONAL   SURGERY 

coryza  promptly  followed  by  the  constitutional  symptoms,  or  the  nose 
may  become  involved  in  the  course  of  the  disease.  In  the  beginning 
the  nasal  mucous  membrane  becomes  thickened,  reddened,  very  sensi- 
tive, and  dry,  after  which  a  thick  secretion  forms.  There  is  intense 
headache  and  anosmia,  with  involvement  of  the  sinuses  which  increases 
the  pain  and  headache.  First,  the  ethmoidal  cells  are  usually  involved, 
then  one  or  all  of  the  frontal,  antral,  or  sphenoidal  sinuses,  with  the 
accompanying  pain,  tenderness,  and  eye  symptoms  as  described  under 
acute  sinus  disease.  As  the  thickening  of  the  nasal  mucous  membrane 
is  not  materially  relieved  by  local  applications,  it  is  desirable  to  use  only 
mild  and  non-irritating  treatment,  such  as  employing  warm  saline 
douches,  oil  sprays,  and  the  external  heat  from  leucodescent  lamps, 
hung  near  the  infected  parts,  which  heat  will  relieve  the  pain  more  effect- 
ively than  the  heat  from  a  hot-water  bag.  The  accessory  sinuses  often 
will  be  found  secreting  pus  months  or  even  years  after  the  acute  symp- 
toms of  the  influenza  have  abated,  the  anosmia  or  parosmia  persisting, 
especially  in  the  cases  with  purulent  secretion  from  the  sinuses;  the 
anosmia,  when  due  to  the  presence  of  pus,  subsides  after  the  sinuses  are 
well,  but  the  prognosis  is  poor  if  the  loss  of  smell  is  directly  due  to  the 
influenza  infection.  The  treatment  of  the  chronically  infected  sinus 
will  be  considered  under  "Sinuses." 

Pus  Organisms  in  General. — The  staphylococcus  pyogenes  aureus, 
citreus  and  albus,  various  forms  of  streptococcus,  micrococcus  pneu- 
moniae (Frankel),  bacillus  of  pseudodiphtheria,  bacillus  foetidus,  dip- 
lococcus  ozenae,  colon  bacillus,  Friedlander's  capsule  bacillus,  meningo- 
coccus intracellularis,  and  the  influenza  bacillus  have  all  been  found  in 
purulent  conditions  of  the  nose.  Pus  in  the  nose  is  strong  evidence  of 
sinus  involvement,  which  is  generally  a  mixed  infection  involving  some 
of  the  sinuses,  as  a  purulent  secretion  rarely  is  limited  to  the  nasal 
mucous  membrane. 

Typhoid. — The  nasal  mucosa  frequently  exhibits  passive  congestion 
during  typhoid  fever,  and  in  the  last  stages  of  the  disease  ulcers  may 
appear  upon  the  septum  and  at  times  upon  the  turbinates.  The 
septal  ulceration  is  apt  to  be  deep,  involving  the  cartilage  and  bone  and 
resulting  in  perforation  of  the  septum. 

Tuberculosis  of  the  Nose. — This  infection  is  quite  rare.  A  granu- 
loma with  a  sessile  base  may  be  found  upon  the  septum,  which  is 
generally  pink  or  gray  in  color,  and  has  a  granular  surface  which  cannot 
be  distinguished  clinically  from  a  syphilitic  granuloma,  a  section  of 
which  growth,  under  the  microscope,  will  show  the  presence  of  giant 


NOSE  263 

cells  or  of  miliary  nodules  containing  the  giant  cells,  which  microscopic 
findings  could  hardly  be  considered  as  final  in  the  determination  of 
the  question  as  to  syphilis  or  tuberculosis,  as  such  features  are  some- 
times present  and  sometimes  absent  in  both  of  the  diseases.  It  is 
scarcely  necessary  to  mention  that  caseation  and  other  degenerative 
processes  occur  in  syphilis  as  in  tuberculosis,  and  that  the  presence  or 
absence  of  these  retrogressive  metamorphoses  do  not  constitute  a 
distinctive  sign  between  these  diseases;  nor  is  the  production  of 
connective  tissue,  which  leaves  familiar  scar-formation,  a  reliable 
sign. 

Arteritis,  leading  to  vascular  obliteration,  is  often  quoted  as  a 
characteristic  feature  of  syphilis,  and  as  a  matter  of  fact  this  condition 
is  almost  constantly  found.  However,  this  vascular  change  is  not 
entirely  conclusive,  as  it  is  met  with  in  tuberculous  conditions  as  well, 
the  giant  cells  in  syphilitic  lesions  perfectly  resembhng  Langerhans' 
giant  cells  met  with  in  tuberculosis.  Some  medical  authors  maintain 
that  the  giant  cells  originate  by  individual  growths  from  a  single  cell, 
while  others  assert  that  several  cells  are  concerned  in  their  growth. 
The  general  tendency  seems  to  be  to  regard  them,  on  account  of  their 
parietal  nuclei,  as  cross  sections  of  preexisting  vascular  or  lymph 
channels.  But  whatever  their  true  origin,  it  may  be  assumed  that 
they  are  the  same  in  both  tuberculosis  and  S3^hilis.  The  only  con- 
clusion then  that  can  be  drawn  is  that  the  microscopical  and  the  clinical 
pictures  cannot  be  absolutely  relied  upon.  Unless  the  tubercle  bacilli 
can  be  demonstrated  in  the  tissues  or  by  inoculation,  we  should  con- 
sider the  condition  as  syphilitic.  The  ordinary  doses  of  mercury  and 
potassium  iodide  will  show  poor  results  in  these  granular  conditions,  the 
administration  of  doses  to  the  point  of  toleration  for  a  lengthy  period 
of  time  being  needful  for  satisfactory  results. 

Lupus  of  the  nasal  mucosa  has  the  same  characteristics  as  that  on 
the  skin  about  the  nasal  orifice.  This  condition  is  rare  in  the  native 
born. 

The  treatment  of  nasal  tuberculosis  is  to  remove  as  much  of  the 
infected  area  as  possible  with  the  curette  or  with  the  electric  cautery. 

Syphilis  of  the  Nose. — Primary  lesions  within  the  nasal  orifice 
occasionally  occur  from  a  contaminated  finger  or  surgical  instrument. 
They  appear  usually  upon  the  septum,  but  sometimes  deeper,  especially 
when  caused  by  unsterilized  instruments,  such  as  a  Eustachian  catheter, 
the  chancre  being  usually  painless,  unless  the  swelling  causes  pressure. 
The  swelling  is  circumscribed,  ulcerates  rapidly,  and  the  submaxillary 


264  REGIONAL   SURGERY 

lymph-glands  become  slightly  enlarged,  freely  movable,  hard,  and 
painless;  the  secondary  symptoms  resemble  a  simple  coryza  and  are 
characterized  by  redness,  swelling  and  congestion,  at  first  with  a  thin, 
watery  discharge,  which  later  becomes  thick  and  finally  purulent 
with  a  fetid  odor.  At  times  mucous  patches  appear  within  the 
vestibule.  The  tertiary  lesions  are  superficial  or  deep  ulcerations  or 
granulomata.  These  lesions  first  appear  as  a  purplish  or  reddish 
swelling,  subsequently  softening;  if  large  enough,  this  swelling  will 
cause  obstruction  and  neuralgic  pains.  The  superficial  ulcers  have 
sharply  defined  edges  with  no  congested  areolae  and  with  their  centers 
covered  with  muco-pus,  while  the  deep  ulcers  are  the  result  of  broken- 
down  gummata  and  tissue  necrosis,  producing  an  offensive  odor  which 
once  recognized  will  never  be  forgotten.  The  necrosis  is  followed  by 
contracting  scar-tissue,  the  resulting  disfigurement  depending  upon 
the  location  of  the  destroyed  tissue,  and  if  the  lesion  has  involved  the 
nasal  bones  or  cartilaginous  septum  and  has  not  been  promptly  arrested 
with  treatment,  the  nose  will  afterward  become  flattened.  The 
S3rphilitic  granulomata  are  very  chronic  and  as  a  rule  do  not  break  down 
or  cause  destruction  of  the  tissue. 

Diagnosis. — The  aid  of  the  bacteriologist  should  be  sought  for 
detecting  the  presence  of  the  spirochseta  pallida  in  both  primary  and 
secondary  lesions  of  the  patient.  CHnically,  the  tertiary  lesions 
are  the  easiest  to  diagnose,  but  as  syphilis  may  closely  resemble  both 
tuberculosis  and  malignancy,  a  Wassermann  test  should  be  made 
and  a  section  of  tissue  submitted  to  the  pathologist  for  examination, 
as  both  tuberculosis  and  malignant  growths  may  show  some  improve- 
ment under  mercurial  treatment,  and  thereby  valuable  time  be  lost. 

Treatment. — Administration  of  salvarsan  or  mercury,  preferably  by 
injections,  is  most  strongly  advised.  Only  non-irritating  sprays  or 
douches  of  normal  saline  solution  or  of  oils  should  be  used  locally  for 
the  primary  and  secondary  lesions.  The  necrotic  portion  should  be 
removed  in  the  tertiary  lesions  and  the  ulceration  made  as  healthy 
as  possible  with  astringents,  such  as  silver  nitrate,  50  per  cent,  solution, 
or  Hquor  hydrargyri  nitratis,  25  per  cent,  to  50  per  cent,  solution,  the 
latter  being  more  painful. 

Congenital  Nasal  Syphilis. — In  infancy,  syphilis  is  quite  character- 
istic on  account  of  the  shriveled  infant  with  the  "snuffles,"  and  with  a 
coryza  which  is  apt  to  be  more  severe  than  it  is  in  adults  and  cause  much 
distress  while  the  child  is  feeding  and  breathing.  Fissures  about  the 
nares  are  common,  followed  by  the  flattened  nose,  due  more  to  mal- 


NOSE  265 

development  than  to  necrosis;  otherwise  the  nasal  symptoms  are 
similar  to  those  of  the  acquired  form. 

Glanders  (rare). — This  is  a  contagious  disease  in  horses  which  is 
rarely  transmitted  to  man,  but  when  it  is,  the  primary  lesion  is  fre- 
quently located  in  the  nose.  Constitutional  symptoms  are  severe  in 
acute  cases,  the  patient  rapidly  assuming  the  typhoid  state  with  small 
submucous  granular  tumors  forming  in  the  nose,  which  tumors  rapidly 
ulcerate,  giving  rise  to  a  very  oflfensive  discharge,  with  a  swelling  of 
the  nasal  mucous  membrane,  which  is  not  usually  painful,  and  with 
necrosis  of  the  bone  and  cartilage  ensuing  and  adenitis  developing. 

Diagnosis. — The  diagnosis  can  be  definitely  made  by  identifying  the 
bacillus  mallei  in  stained  smears  of  the  discharge,  or  by  animal  inocula- 
tion. The  last  stages  of  the  disease  may  closely  resemble  typhoid 
fever  or  pyaemia. 

Treatment. — Open  the  abscesses,  and  then  use  douches  of  potassium 
permanganate  solution. 

Leprosy  (rare). — This  disease  is  observed  for  the  most  part  in  the 
foreign  born,  and  is  very  slightly  infectious  to  the  native  American. 
This  disease  is  caused  by  an  infection  from  the  bacillus  lepra?.  The 
mode  of  the  infection  is  still  unknown.  The  nasal  lesions  are  part  of  the 
general  disease,  and  are  of  the  anaesthetic  and  nodular  types.  In  the 
case  of  the  latter  type,  the  mucous  membrane  first  becomes  red,  then 
thickens,  becoming  lighter  in  color,  at  which  time  the  nodules  appear 
in  the  submucous  strata  and  are  composed  of  granulation  tissue  which 
eventually  breaks  down,  forming  ulcers  from  the  size  of  a  nodule  to  the 
destruction  of  bone  and  cartilage. 

Diagnosis. — Diagnosis  is  usually  made  very  easily  from  the  lesions 
on  the  skin,  although  these  lesions  sometimes  closely  resemble  tertiary 
syphilis,  which  doubt  can  be  ruled  out  by  mercurial  administration. 
A  positive  diagnosis  of  the  condition  can  be  made  by  identifying  the 
leprosy  bacillus  in  the  nodules  or  in  the  discharge  from  the  ulcerated 
lesions.  A  Wassermann  test  is  of  little  value,  as  it  usually  gives  a 
positive  reaction  in  leprosy. 

Prognosis. — The  disease  is  usually  fatal,  but  there  are  a  few  reported 
cures. 

Treatment. — Chaulmugra  oil  is  recommended,  using  as  many  as  60 
drops  daily. 

Actinomycosis. — This  infection  is  only  mentioned  as  a  possibility. 

Scleroma. — Scleroma  of  the  nasal  passages  is  caused  by  the  bacillus 
of  Frisch  (Friedlander).     The  characteristic  microscopical  elements  in 


266  REGIONAL   SURGERY 

the  granuloma  are  the  bacillus,  "foam  cells,"  hyaUne  bodies,  and  round- 
cell  infiltration.  The  nodules  first  appear  in  the  neighborhood  of  the 
orifice  or  nasal  vestibule,  then  extend  outward  upon  the  upper  Hp, 
sometimes  upon  the  face,  and  occasionally  backward  into  the  naso- 
pharynx and  larynx.  They  are  red,  soft,  and  at  first  sharply  defined, 
then  they  become  paler  in  color,  hard,  and  diffuse  with  scar  tissue  and 
contraction,  resulting  in  repeated  epistaxis  and  occlusion  of  the  nose, 
the  surface  becoming  slightly  eroded,  with  crust  formation  and  a 
characteristic  garlic-like  odor. 

Diagnosis. — Diagnosis  is  not  always  easy.  The  involvement  of  the 
pharynx  and  larynx  affords  some  aid,  and  clinically  the  hard,  rigid 
and  non-ulcerating  granuloma  is  suggestive,  and  the  Frisch  bacillus, 
foam  cells  and  hyaline  bodies  observed  microscopically  in  the  excised 
tissue,  and  a  pure  culture  of  the  bacilli  obtained  from  the  blood  of  the 
lesion,  will  confirm  the  diagnosis. 

Treatment. — Drugs  are  of  Httle  value.  Surgery  is  indicated  in  so 
far  as  it  may  relieve  the  nasal  obstruction.  The  X-ray  gives  the  best 
results,  but  unfortunately  it  does  not  reach  the  lesions  deep  within  the 
nose,  while  vaccines  give  varying  results. 

TUMORS,  BENIGN 

Nasal  Polyp. — Benign  nasal  polyp  is  the  most  frequent  growth 
within  the  nasal  cavity,  and  is  a  low  grade  of  connective-tissue  tumor, 
often  confused  with  a  polypoid  degeneration  of  the  mucosa  from  puru- 
lent inflammation.  Many  theories  regarding  their  causes  have  been  ad- 
vanced. Personally,  I  beheve  that  they  are  due  to  some  infective  proc- 
ess of  the  mucosa,  existing  or  having  existed,  especially  in  the  ethmoidal 
cells  or  other  accessory  sinuses.  In  color  and  consistency  they  closely 
resemble  a  raw  oyster,  usually  with  a  smooth  surface  and  attached  by  a 
pedicle.  They  vary  in  size  from  a  pea  to  a  mass  entirely  filling  the 
nasal  cavity,  and  may  protrude  from  the  anterior  nares  or  back  into 
the  nasopharynx,  causing  complete  occlusion  and  at  times  spreading 
the  nose  from  pressure  until  the  face  has  a  frog-like  expression.  The 
polypi  may  be  attached  to  any  part  of  the  nasal  mucosa.  Sometimes 
they  are  firm,  with  a  thick  white  surface  over  which  blood-vessels  are 
seen  coursing.  Generally  they  are  composed  of  a  network  of  areolar 
tissue,  the  meshes  of  which  are  filled  with  serum,  fibrin,  and  mucoid 
material,  with  fibrous  stroma  present,  and  covered  with  a  ciliated, 
columnar  epithelium. 


NOSE  267 

Symptoms. — The  symptoms  depend  upon  the  size  and  the  situation 
of  the  polypi.  If  they  are  found  about  the  ethmoidal  region,  anosmia 
and  reflex  symptoms,  such  as  asthma  and  cough,  may  exist.  There 
is  increased  secretion,  but  it  is  not  purulent  or  offensive  unless  some  of 
the  sinuses  are  much  involved.  Occlusion  of  the  nasal  passages  pro- 
duces change  of  voice  and  mouth  breathing.  Pain  and  headache  are 
rarely  present. 

Diagnosis. — Diagnosis  is  easy,  but  it  is  well  to  have  a  microscopical 
examination  in  all  cases  of  prompt  recurrence  after  the  removal  of  the 
polypi,  also  when  the  tumor  is  a  mixed  one,  and  when  it  is  of  a  firm 
consistency. 

Treatment. — Remove  with  a  snare  or,  better,  seize  them  with  a  dull 
forceps  and  suddenly  jerk  them  out.  When  they  are  attached  to  the 
septum  or  nasal  floor,  which  is  rare,  nothing  more  is  needed,  but  when 
attached  to  the  upper  part  of  the  nose,  the  associated  sinus  disease  must 
be  cured  to  prevent  recurrence. 

Papilloma.— Fibropapillomata  are  rare.  They  usually  spring  from 
the  inferior  turbinate  or  septum.  Microscopically,  they  exhibit  hyper- 
trophy of  all  the  normal  elements  of  the  papillae.  They  are  small,  re- 
sembling a  cutaneous  wart,  and  rarely  cause  symptoms. 

Treatment. — Remove  the  tumors,  cauterizing  their  bases. 

Angioma  or  Bleeding  Polyp  of  the  Septtmi. — These  growths,  occur- 
ring on  the  anterior  part  of  the  septum,  are  small,  nodular,  and  sessile. 
They  are  composed  of  blood-vessels  or  blood-channels  in  a  connective- 
tissue  stroma  with  a  covering  of  columnar  epithelium. 

Symptoms. — The  most  prominent  symptom  is  recurrent  epistaxis 
and,  if  the  tumors  are  large  enough,  nasal  obstruction. 

Diagnosis.— T\i&  diagnosis  is  fairly  easy  when  the  growth  is  situated 
upon  the  anterior  part  of  the  septum,  with  a  granular  surface,  soft  in 
consistency,  red  or  purplish  in  color,  occasionally  being  seen  to  pulsate 
and  having  a  great  tendency  to  bleed.  Microscopical  examination 
should  be  made  to  determine  the  nature  of  the  growth. 

Treatment. — Snare  off  very  slowly,  cauterizing  the  base. 

Chondroma. — This  type  of  tumor  is  exceedingly  rare.  It  develops 
from  the  cartilage  of  the  septum,  and  is  of  slow  growth.  The  symptoms 
are  purely  mechanical,  and  when  the  growth  is  of  sufficient  size  to 
obstruct  the  nose,  it  should  be  removed. 

Fibroma. — This  tumor  is  rare,  usually  situated  on  the  middle  or 
inferior  turbinate,  its  pathology  being  the  same  as  that  of  fibrous 
tumors  elsewhere  with  mechanical  symptoms,  except  that  the  erosion 


268  REGIONAL   SURGERY 

of  its  adjacent  membrane  causes  hemorrhage.  It  is  firm  to  the  touch, 
and  may  be  large  enough  to  cause  a  frog-face  expression. 

Treatment. — Remove  with  snare  or  forceps,  and  pack  to  control 
hemorrhage. 

Osteoma. — This  type  of  tumor  may  be  cancellous  or  eburnated, 
and  usually  originates  in  the  upper  part  of  the  nose  or  accessory  si- 
nuses. The  pedicle  may  disappear  and  show  no  signs  of  the  attach- 
ment and  removal. 

Symptoms. — These  are  mechanical,  and  if  of  sufiicient  size,  the 
growth  may  cause  deformity,  invading  the  orbit.  I  have  seen  one 
larger  than  a  hen's  egg  without  bony  attachment,  requiring  the  re- 
moval of  the  anterior  antral  wall,  part  of  the  nasal  bone,  and  part  of 
the  orbital  wall  for  its  delivery. 

Mucocele. — This  type  has  the  appearance  of  a  polyp  with  a  broad 
base,  and  is  in  reality  a  retention  cyst,  containing  a  fluid  in  which  are 
found  albumin  and  mucin. 

Symptoms. — Similar  to  those  of  nasal  polypi. 

Treatment. — Open  and  apply  caustic,  such  as  silver  nitrate,  to  the 
walls. 

Teratoma.— This  is  a  very  rare  congenital  tumor  which  appears  in 
the  nose,  showing  a  variety  of  embryonic  tissue. 

Hemangioma  and  L3miphangioma. — These  growths  are  composed 
of  dilated  capillaries  of  either  kind.  They  are  generally  multiple,  and 
have  a  great  tendency  to  bleed. 

Cysts. — Cysts  may  occur  in  the  nose  as  elsewhere  in  the  body. 
They  present  no  especial  feature  characteristic  of  the  locality. 

TUMORS,  MALIGNANT 

Sarcoma. — Sarcoma,  which  is  rare,  may  arise  from  any  part  of  the 
nasal  cavity,  and  may  be  concealed  by  polypoid  tissue.  The  histological 
structure  and  varieties  are  the  same  as  in  the  other  parts  of  the  body, 
the  small,  round-cell  variety  growing  rapidly,  while  the  large-cell 
variety  is  more  common  and  of  slower  growth,  being  usually  nodular 
and  of  a  soft  consistency. 

Symptoms. — The  first  symptoms  are  obstruction  and  pain,  the 
latter  depending  upon  the  pressure,  then  hemorrhage  from  ulceration, 
with  offensive  discharge. 

Diagnosis. — Diagnosis  should  be  confirmed,  microscopically.  Re- 
move  a   fair-sized   specimen   which   includes   the   deeper   structures; 


NOSE  269 

otherwise  the  microscopical  findings  are  apt  to  be  misleading,  as  the 
sarcomatous  tissue  may  be  overlaid  with  polypoid  tissue. 

Prognosis. — The  prognosis  depends  upon  the  rapidity  of  the  growth, 
the  size  of  the  tumor  when  discovered,  and  the  thoroughness  with  which 
it  is  removed. 

Treatment. — Do  not  dally  with  curetting  or  cauterizing,  but  by  a 
radical  external  operation,  remove  the  entire  growth  with  a  wide  margin 
of  the  healthy  tissue. 

Carcinoma. — Carcinoma,  which  is  rare,  may  be  squamous  or  gland- 
ular. The  squamous  form,  or  epithelioma,  has  pain  as  its  prominent 
symptom,  the  growth  at  first  being  a  nodular  infiltration,  which  breaks 
down  early  into  a  deep,  ragged,  ulcerating  cavity,  accompanied  by  a 
foul  discharge  with  hemorrhage  from  time  to  time;  then  cachexia  ensues. 

Diagnosis. — A  hard,  nodular,  infiltrating  growth,  with  a  deep, 
ulcerating  center  is  strongly  suggestive  of  carcinoma,  but  syphihs 
may  give  the  same  clinical  picture;  therefore,  a  microscopical  examina- 
tion should  be  made.  For  this  purpose,  if  possible,  procure  a  large 
section,  including  a  portion  both  of  the  growth  and  the  adjacent  normal 
tissue,  avoiding,  as  far  as  possible,  the  ulcerated  area,  as  that  often 
shows  nothing  more  than  inflammatory  tissue. 

Prognosis. — Prognosis  is  bad  except  in  very  early  cases,  when  radical 
and  immediate  removal,  including  much  normal  surrounding  tissue. 
may  cure,  or  at  least  prolong  the  patient's  life. 

Treatment. — When  discovered  in  the  early  stage  without  glandular 
involvement  or  much  infiltration,  radical  removal  is  indicated.  When 
the  growth  has  acquired  some  size,  it  is  better  to  use  palliative  treatment. 

Adenocarcinoma  or  Malignant  Adenoma. — The  glandular  carcinoma 
has  a  clinical  appearance  very  different  from  epithelioma,  being  a 
soft  proliferating  growth,  the  surface  of  which  is  red  or  purpHsh,  and 
is  not  apt  to  ulcerate,  and  sometimes  bleeds.  I  have  seen  three  cases, 
all  of  which  originated  in  the  accessory  sinuses,  one  case  having  metas- 
tases, their  post-operative  course  showing  them  to  be  much  less  malig- 
nant than  squamous  carcinoma. 

Treatment. — Radical  removal  even  when  of  considerable  size,  with 
as  much  of  the  adjacent  gland-bearing  tissue  as  possible. 

NASOPHARYNX 

Injuries.- — Trauma  of  the  nasopharynx  is  rare.  I  have  never  seen 
one  due  to  accident.     Occasionally  cases  are  observed  in  which  some 


270  REGIONAL   SURGERY 

crude  operation  has  injured  the  prominence  of  the  Eustachian  tubes 
or  the  operator  has  removed  some  mucous  membrane,  resulting  in  an 
atresia  of  the  nasophar}Tix.  Deformity  and  atresia  of  the  nasopharynx 
are  usually  caused  by  syphilis.  The  relief  of  the  constricting  band  of 
adhesions  is  a  difficult  matter.  Several  methods  have  been  proposed, 
but  the  ultimate  benefit  derived  from  these  may  be  very  slight,  as 
there  is  a  great  tendency  to  fibrous  reconstruction.  This  undoes  most 
of  the  work,  especially  where  the  posterior  surface  of  the  velum  is 
adherent  to  the  post-pharyngeal  wall  which  is  the  usual  deformity. 
Some  method  must  be  used  which  will  provide  epithehum  to  cover  one 
surface  of  the  velum  when  it  is  freed.  Flaps  of  mucous  membrane 
from  the  cheeks  can  be  brought  back  and  fastened  so  as  to  cover  one 
surface  and  thereby  keep  them  apart  while  healing. 

Infections. — Tuberculosis. — So-called  latent  tuberculosis  may  exist. 
This  is  not  appreciable  clinically,  but  is  detected  microscopically. 
Tuberculosis  also  occurs  as  a  late  ulcerative  process,  secondary  to 
pulmonary  involvement.  Both  are  rare,  the  latent  being  the  more 
frequent  of  the  two. 

Lupus. — This  may  involve  the  nasopharynx,  but  it  is  an  extremely 
rare  condition. 

Syphilis.- — Both  congenital  and  acquired  syphilis  may  attack  the 
nasopharynx,  and  the  picture  will  be  found  to  be  similar  to  that  of  the 
nose.     Resulting  contractions,  after  tertiary  lesions,  are  characteristic. 

Glanders. — This  condition  may  extend  from  the  nose  to  the  pharynx. 

Hyperkeratosis. — This  is  a  condition  manifested  by  pearly  white, 
small  tufts  on  the  mucous  membrane,  usually  on  lymphoid  tissue,  and 
may  sometimes  be  seen  in  the  nasopharynx.  It  is  usually  an  extension 
from  the  pharynx.  Its  etiology  is  very  obscure.  Pathologically,  the 
tufts  are  horny-like  growth  of  epithelial  cells  which  have  lost  their 
nuclei.  This  condition  rarely  gives  symptoms,  but  sometimes  patients 
complain  of  a  sensation  of  dryness  and  stiffness  of  the  throat. 

Treatment. — Usually  no  treatment  is  necessary  as  the  lesion  causes 
no  harm.     The  galvano-cautery  into  each  tuft  will  destroy  it. 

Pharyngeal  Tonsil  or  Adenoid. — The  pharyngeal  tonsil  or  adenoid, 
springing  from  the  vault  of  the  nasopharynx,  is  composed  of  lymphatic 
tissue,  which  is  highly  vascular,  and  a  normal  structure  that  should 
atrophy  between  twleve  and  fourteen  years  of  age. 

The  adenoid  should  receive  surgical  attention  whenever  its  re- 
sistance has  been  overcome  by  septic  bacteria  and  there  is  an  enlarge- 
ment of  the  chain  of  the  lymphatic  glands  into  which  it  drains.     These 


NOSE  271 

glands  run  from  the  tip  of  the  mastoid,  downward  and  backward,  and 
are  palpable  only  when  enlarged,  at  which  time  they  range  in  size  from 
that  of  a  French  pea  to  that  of  an  almond.  Adenoids  may  cause 
nasal  catarrh,  sinus  infection,  Eustachian  tube  catarrh,  otitis  media 
(catarrhal  or  purulent).  Long-continued  obstruction  prevents  devel- 
opment of  the  facial  bones  causing  narrow  nasal  passages  and  perma- 
nently impairing  nasal  breathing,  obliging  the  patient  to  breathe 
through  the  mouth  continuously,  usually  leading  to  deformed  chest 
walls,  "chicken  breast,"  also  often  producing  a  high  arch  of  the 
hard  palate  and  a  deformed  dental  arch.  The  child  appears  tired, 
under-weight,  and  bad  tempered,  while  the  open  mouth  gives  a  dull 
facial  expression,  frequently  combined  with  a  concomitant  deafness, 
which  gives  the  child  the  appearance  of  being  stupid.  The  obstructed 
nose  causes  spasmodic  cough,  asthma,  snoring,  restlessness  at  night,  bad 
dreams,  recurrent  coryzas,  and  change  of  voice.  The  direct  connection 
of  the  pharyngeal  lymphatics  with  the  brain  and  pituitary  gland 
often  produces  real  mental  dullness  which  tends  to  disappear  after  the 
removal  of  the  adenoids.  All  of  these  symptoms  are  not  necessarily 
present  in  every  case. 

Diagnosis. — The  adenoid  should  be  inspected  with  a  rhinoscopic 
mirror.  However,  when  this  cannot  be  done,  diagnosis  can  be  made  by 
the  sense  of  touch,  giving  a  better  idea  of  the  extent  of  the  hypertrophy. 
Using  great  care  not  to  injure  nor  to  frighten  the  little  patient,  with 
your  left  arm  and  hand  place  the  child's  head  firmly  against  your  left 
side,  instructing  the  patient  to  open  the  mouth.  Pressing  the  cheek 
inward  between  the  teeth  with  your  left  index-finger,  to  prevent  the 
patient  from  biting,  now  pass  the  index-finger  of  the  right  hand  over  the 
tongue,  depressing  it  as  much  as  possible,  until  the  finger  reaches  the 
post-pharyngeal  wall;  rapidly  pass  the  end  of  the  finger  upward  into  the 
nasopharynx,  sweeping  it  from  side  to  side  to  determine  the  size  of  the 
adenoid;  quickly  withdraw  the  finger,  keeping  away  from  the  haird 
and  soft  palate  to  prevent  the  tendency  to  retching  and  contraction  of 
the  velum.  In  a  very  young  child,  whose  nasopharynx  would  be  in- 
jured if  the  finger  were  introduced,  the  diagnosis  can  be  made  by  placing 
a  stethoscope  behind  the  angle  of  the  jaw,  where  a  roaring  sound,  ac- 
companied by  many  moist  r^les  will  be  heard.  Obstructed  nasal  breath- 
ing, inability  in  infants  to  nurse  without  stopping  to  breathe,  restless 
sleep,  and  ear  complications  tend  to  confirm  the  diagnosis. 

Prognosis. — The  prognosis  is  good  when  the  adenoid  is  discovered 
and  removed  early,  but  not  so  good  when  the  hypertrophy  has  been  of 


272 


REGIONAL   SURGERY 


long  standing  and  the  bones  of  the  face  have  been  retarded  in  develop- 
ment or  when  there  are  changes  in  the  ears. 

Treatment  (Figs.  141  and  142). — There  is  only  one  successful  treat- 
ment and  that  is  total  removal.  It  is  best  to  give  ether,  as  without  an 
anaesthetic  or  under  local  anaesthesia,  the  chances  are  in  favor  of  some  of 
the  lymphoid  tissues  being  overlooked,  leaving  a  source  for  further  hyper- 
trophy and  trouble.  The  methods  and  instruments  for  this  operation 
are  legion.  The  Gottstein  curette  and  one  of  the  many  adenoid  for- 
ceps are  all  that  are  needed,  the  Brandegee  forceps  being  probably  the 


Fig.  141. — Adenoid  curette. 


best  aU-round  instrument.  By  the  sense  of  touch,  using  the  index- 
finger,  the  size  of  the  growth  and  the  contour  of  the  nasopharynx  are 
determined;  then. using  a  curette  fitting  the  particular  case,  endeavor 
to  remove  the  entire  adenoid  with  one  sweep  of  the  instrument.  I  have 
six  different  sizes  of  curettes,  of  which  I  introduce  the  one  best  suited 
to  the  case,  passing  it  upward  behind  the  velum  until  it  comes  into  con- 
tact with  the  posterior  border  of  the  nasal  septum,  then  gently  but 
firmly  pressing  the  curette  backward  until  it  engages  the  growth,  keeping 
the  curette  in  firm  contact  with  the  superior  and  posterior  wall  of  the 


Fig.  142. — Adenoid  forceps.     {Brandegee.) 

nasopharynx,  and  then  passing  it  backward  and  downward,  having  the 
handle  always  in  the  median  line.  This  procedure  will  usually  remove 
the  entire  adenoid  with  the  least  trauma.  If  the  contour  of  the  naso- 
pharyngeal space  is  such  that  the  curette  cannot  engage  all  of  the  growth, 
by  using  the  index-finger,  the  remnants  can  be  felt  and  then  engaged 
with  the  adenoid  forceps;  placing  the  index-finger  behind  the  forceps 
while  withdrawing  them  will  prevent  the  post-pharyngeal  wall  from 
being  stripped.  A  brisk  primary  hemorrhage  will  follow  which  can 
be  checked  to  a  large  extent  by  applying  towels  saturated  with  ice  water 


NOSE  273 

to  the  face.  There  is  rarely  a  secondary  hemorrhage,  but  if  there  should 
be  one,  it  can  be  checked  by  a  post-nasal  tampon. 

Tornwaldt's  Disease. — This  is  a  purulent  infection  of  the  bursa  of 
Luschka,  characterized  by  a  purulent  discharge  and  crusts  on  the 
posterior  nasopharyngeal  wall  or  near  the  vault.  The  discharge  usually 
dries  into  a  crust.  The  secondary  symptoms  are  catarrh  in  the 
Eustachian  tubes  and  cough. 

Treatment. — Removal  of  the  pyogenic  sac  with  the  adenoid  forceps. 

TUMORS 

Fibroma  of  the  Nasopharynx. — This  is  usually  composed  entirely 
of  fibrous,  sometimes  mixed  with  sarcomatous  or  myxomatous  tissues. 
It  is  a  rare,  but  very  serious  condition,  developing  early  in  youth, 
more  often  in  males,  and  originating  from  the  basillar  process  of 
the  occipital  bone,  with  a  tendency  toward  retrogression  after  the 
twentieth  year.  The  symptoms,  depending  upon  which  way  the  growth 
extends,  may  be  nasal  obstruction,  hemorrhage  from  pressure,  change  of 
features,  frog-face,  and  when  the  growth  extends  downward,  its  pressure 
causes  constant  desire  to  swallow.  A  change  of  voice  from  the  obstruc- 
tion and  mouth  breathing  may  result,  while  extension  into  the  cranial 
cavity  causes  headaches,  etc. 

Diagnosis. — A  growth  in  the  nasopharynx  that  is  hard,  grayish  or 
pinkish  in  color,  which  may  be  nodular  or  smooth  with  any  exposed 
surface  in  the  throat  or  with  the  anterior  nares  rough  like  a  hard  papil- 
loma, especially  in  young  males,  is  fairly  conclusive. 

Prognosis. — The  prognosis  depends  largely  upon  its  size.  While 
small,  with  a  few  adhesions  and  extensions,  the  outlook  is  favorable, 
but  if  it  has  extended  into  the  nose,  accessory  sinuses  or  the  brain,  it 
becomes  a  vitally  serious  condition. 

Treatment. — Some  attempts  have  been  made  to  reduce  the  growth 
by  injecting  acids.  These  are  not  satisfactory,  and  the  resulting 
slough  may  lead  to  serious  hemorrhage.  Removal  by  the  natural  pas- 
sages if  possible,  is  the  most  satisfactory  method.  Be  prepared  for  a 
most  profuse  hemorrhage  at  the  time  of  its  removal.  A  pedunculated 
fibroma  can  be  snared  off,  but  it  is  a  waste  of  time  to  try  to  use  the  snare 
on  a  broad  attachment.  The  sessile  variety  can  be  best  removed  by 
evulsion  under  general  anaesthesia,  being  mindful  of  the  severe  hemor- 
rhage that  may  ensue.     Pass  tapes  through  both  nares,  tying  gauze 

tampons  to  the  mouth  end,  using  the  tapes  also  for  tying  the  velum 
18 


274  REGIONAL   SURGERY 

forward  out  of  the  way.  The  growth  is  then  seized  with  a  powerful 
forceps  (Stucky's)  which  is  modelled  after  Brandigee's  adenoid  forceps, 
but  is  much  stronger,  and  the  growth  being  wrenched  from  side  to  side 
and  forward,  the  finger  of  the  other  hand  being  used  as  a  blunt  dissector, 
is  delivered  through  the  mouth.  A  severe  flow  of  blood  follows  the 
detachment  of  the  fibroma,  and  is  promptly  controlled  with  the  tampons 
that  have  been  in  readiness  on  the  tapes  previously  passed  through  the 
nose.     The  tampons  should  be  carefully  removed  after  48  hours. 

Adenoma,  chondroma,  lipoma,  and  papilloma  are  very  rare. 

Fibromyxoma  is  rare,  but  more  frequent  than  fibroma,  and  usually 
springs  from  the  posterior  part  of  the  nose,  growing  downward  into  the 
nasopharynx.  This  condition  differs  from  myxoma  of  the  nose  in  that 
it  contains  more  fibrous  tissue,  and  consequently  is  firmer  to  the  touch, 
and  like  all  benign  growths,  it  gives  symptoms  of  occlusion,  according 
to  its  size. 

Treatment. — Treatment  consists  of  removal  with  the  snare. 

Sarcoma. — Sarcoma  is  very  rare,  springing  from  the  basillar  proc- 
ess of  the  occipital  bone  and  is  usually  of  the  small  round-cell  variety. 
It  is  of  soft  consistency  and  of  rapid  growth,  extending  to  the  adjacent 
structures,  generally  downward  and  often  produces  a  bloody  discharge 
with  an  ofi'ensive  odor. 

Treatment. — This  condition  is  usually  inoperable. 

Carcinoma. — Carcinoma  is  also  very  rare  and  of  slow  growth  with 
obstruction  and  pain  as  the  growth  extends,  and  accompanied  by  a  foul 
discharge.     These  cases  are  generally  inoperable. 

DISEASES  OF  THE  ACCESSORY  SINUSES 

General  Considerations  which  Apply  to  all  Sinuses. — The  normal 
sinuses  are  practically  sterile,  though  microorganisms  can  and  do  enter, 
rapidly  disappearing,  however,  partly  because  of  the  action  of  the 
ciliated  epithelium  and  partly  because  of  the  fact  that  the  secretion  of 
the  sinus  mucosa  inhibits  bacterial  growth. 

Why  then  do  the  sinuses  become  infected? 

Usually  there  is  some  anatomical  abnormahty,  such  as  a  deviated 
septum  or  a  large  middle  turbinate,  or  an  acquired  abnormahty,  such  as 
hypertrophy  or  hyperplasia  of  the  mucosa,  which  closes  off  the  ostia 
of  one  or  more  of  the  sinuses  at  the  time  of  sHght  inflammatory  swelling, 
creating  a  closed  cavity,  and  the  direct  extension  of  this  inflammation 
producing  proper  soil  for  a  purulent  process  in  the  susceptible  individual. 


NOSE 


275 


Extension  by  the  blood  and  lymph  channels  may  occur,  but  this  is 
extremely  rare.  Some  of  the  predisposing  causes  are  exposure  to  cold, 
automobiling,  cold  baths,  foreign  bodies,  etc.  Sinus  infections  are 
frequent  compHcations  of  epidemic  influenza,  pneumonia,  measles, 
scarlet  fever,  tuberculosis,  syphilis,  typhoid  fever,  cerebro-spinal  menin- 
gitis, diphtheria,  and  erysipelas.  The  most  frequent  immediate 
causes  are  recurrent  infective  inflammation  of  the  nose  (coryzas),  in- 
fluenza and  pneumonic  infections,  and  in  about  35  per  cent,  the  antrum 
is  infected  from  diseased  teeth.  The  usual  infecting  organisms  are 
streptococci,  staphylococci,  pneumococci,  influenza  bacilli,  and  other 
pyogenic  germs.  In  acute  cases  the  infection  may  be  pure,  but  in  all 
chronic  cases  the  infection  is  most 
decidedly  mixed. 

Trauma  may  cause  infective  in- 
flammation in  the  frontal  sinus  or 
the  antrum,  but  is  extremely  rare. 

Pathology. — In  acute  conditions 
the  mucosa  shows  changes  similar 
to  those  of  any  infected  mucosa, 
viz.,  lymph  in  the  intercellular 
spaces  and  a  varying  amount  of 
polynuclear  and  round-cell  infiltra- 
tion, while  chronic  cases  show  poly- 
poid degeneration,  increase  of  fibrous 
tissue,  and  round-cell  infiltration. 

To  clearly  understand  why  the 
orifices  of  the  sinuses  are  easOy 
occluded  some  knowledge  of  the  anatomy  of  the  external  nasal  wall 
is  necessary  (Fig.  143).  From  the  nasal  floor  upward  to  the  attachment 
of  the  inferior  turbinate  is  a  thin  plate  of  bone  which  is  important  be- 
cause through  this  bony  wall  the  needle  punctures  and  the  intranasal 
operation  for  antral  disease  are  done.  The  most  important  region  is 
situated  above  the  inferior  turbinate,  viz.,  the  hiatus  semilunaris,  which 
might  be  termed  a  curved  gutter,  convexity  downward,  extending 
from  a  point  external  to  the  anterior  attachment  of  the  middle  tur- 
binate backward  to  about  half  the  length  of  the  middle  turbinate.  A 
cross-section  of  the  hiatus  is  usually  pear-shaped,  the  deeper  portion 
being  termed  the  infundibulum,  the  lower  boundary  the  uncinate  proc- 
ess, and  the  upper,  the  ethmoidal  bulla,  internally,  the  middle  tur- 
binate hanging  like  a  curtain;  consequently,  when  the  turbinate  is 


Fig.  143. — Lateral  wall  of  the  nasal 
cavity.  A,  Frontal  sinus;  B,  orifice  of  the 
frontal  duct;  C,  hiatus  semilunaris;  D, 
ostium  of  the  antrum;  E,  orifices  of  the 
ethmoidal  cells;  F,  sphenoidal  cell.  The 
removed  middle  turbinate  is  outlined  by 
dotted  line. 


276  REGIONAL   SURGERY 

hypertrophied  or  crowded  over  against  the  opening  of  the  hiatus  by  a 
septal  deviation,  the  drainage  of  the  latter  can  be  easily  impeded  by  an 
inflammatory  swelling. 

The  orifice  of  the  frontal  duct  opens  at  the  anterior  end  of  the 
hiatus  and  all  of  the  anterior  ethmoidal  cells  drain  into  it,  while  the 
antral  orifice  is  at  the  posterior  end;  therefore,  the  pus  appearing  under 
the  middle  turbinate  must  come  from  the  frontal  sinus,  anterior  eth- 
moidal cells  or  from  the  antrum. 

Above  the  hiatus  is  found  the  ethmoidal  labyrinth,  roughly  a 
parallelogram,  bounded  below  by  the  hiatus  and  the  middle  turbinate, 
externally,  by  the  orbit,  superiorly,  by  the  anterior  cranial  fossa, 
and  internally,  by  the  olfactory  fissure,  the  latter  leading  to  the  cribri- 
form plate.  The  posterior  ethmoidal  cells  have  their  orifices  above  the 
middle  turbinate  in  one  or  two  furrows  on  the  inner  wall  of  the 
labyrinth. 

The  sphenoidal  sinuses  occupy  the  body  of  the  sphenoidal  bone, 
with  frequent  extensions  into  the  greater  and  lesser  wings,  the  orifice 
being  near  the  roof  of  the  sinus  and  opening  through  the  anterior  wall 
of  the  sphenoidal  bone  into  the  sphenoidal  fissure. 

Symptoms. — The  most  frequent  symptom  is  pus  or  muco-pus,  dis- 
charging anteriorly  or  posteriorly  from  the  nose,  though  lack  of  history 
of  secretion  or  absence  of  pus  in  the  nose  do  not  necessarily  rule  out 
sinus  disease. 

Anosmia  and  cacosmia  are  strongly  suggestive  of  sinus  involve- 
ment. The  blocking  up  of  the  olfactory  fissure  with  swollen  mucosa 
and  the  toxic  effects  of  the  pus  on  the  olfactory  filaments,  regularly 
lead  to  loss  of  smell,  while  stale  pus,  infected  with  saprophytic  organ- 
isms, produces  an  offensive  odor  which  is  exceedingly  disagreeable  to 
the  patient  if  he  has  retained  his  sense  of  smell  and  to  his  acquaintances. 

Headache. — There  may  or  may  not  be  local  or  general  headache, 
though  usually  it  is  a  symptom  in  acute  cases,  and  its  constant  presence 
which  is  due  to  pressure,  to  irritation  of  the  mucosa,  to  ulcerations 
or  to  toxins  in  chronic  cases  is  to  be  considered  a  grave  symptom. 
Some  practitioners  consider  certain  locations  of  the  headache  as  indi- 
cative of  a  sinus  being  involved,  but  I  deem  it  as  quite  an  unreliable 
sign,  as  irritation  of  any  branch  of  the  trigeminal  nerve  may  produce 
pain  or  headache  in  some  other  branch.  For  instance,  antral  disease 
may  produce  frontal  headache  or  pains  in  the  upper  or  lower  teeth 
and  ethmoidal  disease  may  produce  headache  or  pain  over  the  frontal 
sinus. 


NOSE  277 

Neuralgia  may  be  caused  by  involvement  of  one  of  the  sinuses. 
Headache  and  neuralgia  are  so  often  symptoms  of  sinus  disease  that 
in  all  cases  the  sinuses  should  be  carefully  examined.  Stooping, 
any  sudden  jar,  jumping,  or  any  movement  tending  to  a  sudden  in- 
crease of  intracranial  pressure  usually  aggravate  the  headache  and 
neuralgia. 

Tenderness  in  frontal  sinusitis  is  usually  present  on  the  anterior  and 
inferior  walls,  and  in  antral  infections  over  its  anterior  wall.  Tender- 
ness may  also  be  ehcited  on  the  anterior  sphenoidal  wall  by  means  of  a 
probe,  passed  through  the  nose  after  cocainization  when  the  sphenoid 
is  involved.  In  acute  cases  tenderness  is  usually  present  and  frequently 
in  chronic  cases,  especially  about  the  frontal  sinus.  Percussion  of 
the  anterior  frontal  wall  often  produces  pain  over  the  limits  of  the 
affected  sinus.  Dizziness  and  sometimes  vertigo  are  observed  in  some 
cases  of  frontal  and  ethmoidal  disease. 

General  Symptoms. — The  general  symptoms  are  similar  to  those  of  a 
localized  septic  process  in  any  other  cavity  with  osseous  walls,  and  if 
there  is  an  outlet  for  the  secretion,  there  will  be  but  a  sHght  rise  of 
temperature  and  pulse,  but  if  the  ostium  is  occluded,  a  rather  stormy 
time  ensues  with  increase  of  temperature  and  pulse.  Occasionally, 
in  chronic  cases  of  long  standing,  there  is  a  toxic  tachycardia  which 
continues  for  months  after  the  sinuses  are  well.  The  secretion  may 
produce  chronic  laryngitis  and  bronchitis  with  cough,  also  general 
symptoms,  which  may  be  associated  with  any  other  chronic  septic 
process  in  the  body,  such  as  gastric  disturbances,  constipation,  neur- 
asthenia, mental  dullness,  melanchoha,  etc. 

Diagnosis. — The  detection  and  location  of  an  infected  sinus  or 
sinuses  are  at  times  tedious  and  difficult. 

Locating  the  Source  of  the  Secretion. — In  acute  cases  the  nasal  mucosa 
may  be  greatly  congested  and  swollen.  In  such  cases  the  first  step 
is  to  reduce  this  condition  with  cocaine,  i  per  cent,  solution,  and  supra- 
renal solution,  3^10,000;  then  thoroughly  cleanse  the  nose  and  look 
for  a  discharge,  which  if  it  shows  beneath  the  middle  turbinate  is 
from  the  frontal  sinus,  antrum  or  anterior  ethmoidal  cells,  if  be- 
tween the  middle  turbinate  and  septum,  it  comes  from  the  posterior 
ethmoidal  cells  or  sphenoidal  sinuses,  but  if  secretion  seems  absent,  its 
presence  may  be  made  obvious  by  means  of  the  use  of  the  suction 
apparatus  (Fig.  144).  The  anterior  nares  are  closed  with  the  tips  of 
the  suction  tubes,  and  the  patient  requested  to  say  "K,"  which  will 
close  the  posterior  nares,  and  the  suction  may  produce  the  secretion, 


278 


REGIONAL   SURGERY 


especially  from  the  frontal,  ethmoidal  cells  or  sphenoidal  sinuses. 
This  secretion,  as  it  becomes  visible,  is  engaged  in  a  small  silver  cannula, 
the  secretion  stringing  out  toward  the  sinus  from  which  it  comes.  This 
procedure  is  not  quite  so  reliable  and  easy  in  the  case  of  the  antrum  on 
account  of  the  situation  of  its  ostium. 


Fig.  144. — Brawley's  suction  apparatus. 

The  nasopharyngoscope  of  Holmes  (Fig.  145)  is  of  great  value  in  de- 
tecting secretion  from  the  sphenoidal  sinus  and  posterior  ethmoidal 
cells.  Passing  the  instrument  along  the  floor  of  the  nose,  directing  the 
light  upward;  as  it  passes  backward,  strings  of  pus  can  be  plainly  seen 
coming  from  the  sinuses.  Now  by  passing  the  instrument  beyond  the 
posterior  border  of  the  septum,  the  opposite  side  can  be  inspected  for 
a^  short  distance,  and  if   the  middle  turbinate  has  been  removed   or 


'^ 


■H-ITiBfTr  r'"   " 


Fig.  145. — Holmes  naso-pharynogoscope. 

is  atrophied,  the  ostia  of  the  antrum,  the  anterior  ethmoidal  cells  and 
frontal  sinuses  may  be  inspected,  proving  the  great  aid  and  value  of  this 
instrument. 

The  cannula  and  douche,  as  a  means  for  detecting  secretion,  are  not 
so  easily  used,  as  the  orifices  of  the  anterior  sinuses  are  covered  by  the 
middle  turbinate,  and  frequently  a  septal  deviation  prevents  reaching 
the  sphenoidal  sinus.  Infracting  the  middle  turbinate  will  usually  give 
access  to  the  frontal  sinus  and  antrum,  but  more  positive  results  can  be 


NOSE 


279 


gained  in  the  antrum  by  needle  puncture  of  the  nasoantral  wall,  the 
bone  being  thin  under  the  inferior  turbinate.  The  field  having  been 
anaesthetized,  a  curved  needle  is  passed  under  the  inferior  turbinate, 
about  half  an  inch  from  the  anterior  attachment,  and  with  a  quick 
twist  of  the  wrist  it  is  passed  through  the  antral  wall;  if  it  does  not 
readily  enter,  tap  it  lightly  with  a  mallet,  using  great  care  not  to  enter 
the  orbit  by  passing  the  needle  too  far,  and  also  not  to  drive  fluid  into 
it  under  too  great  a  pressure.  Now  douche  gently  and  if  resistance  is 
encountered,  proceed  very  slowly  and  carefully,  using  plenty  of  fluid, 
as  the  secretion  may  be  thick,  and  the  first  flow,  therefore,  show  no  re- 
sults. Changing  the  tip  of  the  needle  a  trifle  may  improve  the  flow, 
resistance  to  the  return  flow  meaning  a  thickened  or  polypoid  membrane. 
The  finding  of  pus  in  the  antrum  does  not  necessarily  imply  that  the 
antrum  is  diseased  as  it  may  at  times  be  merely  the  reservoir  for  frontal 
or  ethmoidal  pus. 

To  douche  the  frontal  sinus  the  middle  turbinate  must  be  infracted 
or  removed  in  all  but  a  small  per  cent,  of  cases.  A  small  silver  cannula, 
bent  at  nearly  a  right  angle  and  measuring  ^^  in.  from  the  bend  to 
the  tip,  can  be  introduced  into  the  frontal  sinus.  In  order  to  be  sure 
that  the  cannula  is  in  the  sinus  and  not  in  an  anterior  cell,  the  shaft 
should  lie  easily  upon  the  upper  lip  and  parallel  to  it,  and  the  tip  will 
rotate  to  some  extent  within  the  sinus.  If  the  frontal  sinus  and  anterior 
ethmoidal  cells  are  infected  as  well  as  the  antrum,  the  upper  sinuses 
should  be  drained  first  in  order  to  make  sure  that  the  antrum  is 
not  a  reservoir.  If  the  cannula  can  be  passed  through  the  olfactory 
fissure  to  the  anterior  sphenoidal  wall,  the  sphenoidal  orifice  may  be 
entered  by  slight  rotation  outward,  or  if  the  middle  turbinate  has  been 
removed,  the  orifice  can  be  entered  under  inspection. 

The  Rontgen  ray  (Fig.  146)  is  a  most  valuable  aid,  and  should  be 
used  in  every  case  where  there  is  doubt  and  where  operative  procedure 
is  contemplated,  though  the  findings  should  not  be  considered  as  ab- 
solute. Only  an  expert  can  make  a  satisfactory  X-ray  plate  and  con- 
siderable training  is  necessary  for  the  surgeon  to  interpret  the  plate 
which  will  show  the  size,  height,  depth,  recesses,  and  septa  within  the 
sinuses,  and  to  a  certain  degree,  the  condition  of  the  membrane  and  its 
contents.     Antero-posterior  and  lateral  plates  should  be  made. 

Transillumination  (Fig.  147)  should  be  a  routine  office  procedure  in 
examining  every  nasal  case,  as  it  may  show  conditions  which  might 
otherwise  be  overlooked,  and  if  on  transillumination,  done  by  placing 
the  hooded  lamp  on  the  floor  of  the  sinus,  above  the  inner  angle  of  the 


28o 


REGIONAL   SURGERY 


eye,  one  side  of  the  frontal  sinus  is  dark  when  compared  with  the  other, 
more  extended  examination  of  the  sinus  is  suggested,  the  same  holding 
true  of  the  antra.  If  the  exposed  lamp,  placed  in  the  mouth,  shows 
less  glow  on  one  side,  especially  just  under  the  eye,  attention  is  drawn 


Fig.  146. — X-ray  of  the  nasal  accessory  sinuses,  showing  disease  in  the  left  frontal  and 
ethmoidal  cells.     The  probe  is  in  the  frontal  sinus. 

to  that  antrum,  this  method  being,  however,  unreliable,  both  because 
the  accessory  sinuses  vary  in  size,  and  also  because  of  the  thickness  of 
the  walls. 


V,  MUELLER  a  00.. 


Fig.   147. — Haden's  transilluminating  lamps. 

Prognosis. — Nearly  all  acute  cases  recover,  while  chronic  cases  are 
probably  never  cured  without  operative  procedure,  not  however  proving 
fatal,  although  some  of  the  complications  may  readily  terminate  fatally. 

Complications. — The  complications  are  oedema  of  the  lids,  fistulee, 
conjunctivitis,  lesions  of  the  cornea  and  retina,  loss  of  accommodation, 


NOSE  281 

contracted  color  fields,  orbital  abscess,  muscular  immobility,  throm- 
bosis of  the  central  vein  of  the  retina,  cavernous  sinus  thrombosis, 
optic  neuritis  which  may  be  toxic  or  from  pressure,  meningitis,  brain 
abscess  and  the  sinus  focus,  which  is  the  cause  frequently  overlooked. 

Treatment. — It  is  understood  that  there  are  all  cases,  acute  and 
chronic,  ranging  from  quite  mild  to  extremely  severe;  the  treatment, 
therefore,  has  to  meet  varying  conditions.  As  here  outlined,  it  is  for 
the  average  well-marked  case,  acute  cases,  showing  a  strong  tendency 
toward  spontaneous  recovery,  recurrent  attacks,  however,  probably 
leading  to  chronicity.  A  nasal  douche  of  normal  saline  solution,  as 
warm  as  the  patient  can  endure  it  (about  ii5°F.)  every  two  hours,  and 
thorough  shrinking  of  the  nasal  mucosa  with  cocaine  solution,  i  per  cent., 
and  adrenalin  solution,  HojOOOj  once  or  twice  a  day  wull  greatly  relieve 
the  congestion  and  promote  better  drainage,  while  the  leucodescent 
lamp  or  even  on  ordinary  incandescent,  32-c.p.  electric  lamp,  hung  a 
short  distance  from  the  location  of  the  pain,  or  hot  compresses  will  be 
found  to  greatly  alleviate  the  sufferings  of  the  headache  and  neuralgia, 
in  from  24  to  48  hours.  But  in  chronic  cases,  the  sinuses  involved  hav- 
ing been  determined  and  treated,  free  drainage  should  be  established  as 
soon  as  possible,  as  medical  treatment  is  of  little  value.  It  is  a  rare 
condition  to  have  one  sinus  infected  and  the  others  normal,  generally 
two  or  more  being  involved. 

The  ethmoidal  cells,  containing  purulent  secretion  and  degenerated 
polypoid  membrane,  are  the  most  frequently  involved,  and  may  infect 
the  frontal  sinus,  antrum,  or  sphenoidal  sinus  secondarily. 

After  anaesthetizing  the  nose,  remove  the  middle  turbinate,  and  then 
with  biting  forceps,  remove  as  much  of  the  ethmoicfal  labyrinth  as  can 
be  seen.  The  anterior  cells  are  harder  to  remove  than  the  posterior, 
and  their  total  removal  is  usually  impossible  through  the  nose;  generally 
it  takes  several  sessions  to  get  out  as  much  as  necessary,  as  working  in 
a  bloody  field  is  extremely  dangerous,  because  of  the  proximity  to  the 
brain  a,nd  orbit.  Some  of  the  operative  complications  are  emphysema, 
hemorrhage  into  the  orbit  and  eyelid,  and  from  the  ethmoidal  vessels, 
and  meningitis,  all  of  which  can  be  avoided  with  due  care.  The  external 
indications  and  operation  for  exenteration  of  the  ethmoidal  labyrinth 
are  quite  similar  to  those  of  the  frontal  sinus. 

The  antrum  is  the  next  sinus  in  frequency  of  involvement,  often 
relieved  with  quite  conservative  treatment,  providing,  however,  that 
the  frontal  sinus  or  ethmoidal  cells  are  not  infected.  Determine 
whether  the  infection  comes  from  the  nose  or  teeth.     There  is  a  great 


282 


REGIONAL    SURGERY 


liability  to  offensive  odor  in  dental  infection,  while  douching  the  antrum 
with  cold  water  may  locaKze  a  pain  about  the  offending  tooth.     The 


Fig.  148. — Line  of   the   detachment  of  Fig.    149. — The    dark    areas    illustrate 

the  inferior  turbinate.     The  dotted  vertical  amount  of  the  naso-antral  wall  removed, 

line  shows  the  line  of  the  fracture  of   the  Dotted  lines^are  the  limits  of  the  antrum, 
turbinate. 

X-ray  is  the  surest  method  of  determining  the  condition  of  the  roots  of 
the  teeth.     If  the  infection  is  located  in  or  about  a  tooth  root,  the  re- 


FiG.  150. — Wagner's  antral  forceps. 


moval  of  the  tooth  is  indicated.     The  conservative  "^dental 'methods 
of  opening  the  tooth  root  and  treating  it  usually  fail  to  cure  the  infec- 


NOSE 


283 


tion.  After  the  removal  of  the  tooth,  a  few  douchings  of  the  antrum 
will  clear  up  the  discharge.  In  a  large  per  cent,  of  uncomplicated  non- 
dental  cases,  daily  douching  of  the  antrum  by  means  of  the  needle 
puncture  (as  outlined  under  diagnosis)  will  effect  a  cure.  I  have  re- 
cently had  some  very  brilliant  results  by  fiUing  the  antrum  daily  with 
Beck's  bismuth  paste.  (This  treatment  works  equally  well  in  the 
frontal  and  sphenoidal  sinuses  of  both  acute  and  chronic  cases.)  If 
improvement  and  a  cure  do  not  result  in  from  six  to  eight  weeks,  the 
antrum  should  be  drained  into  the  nose  under  the  inferior  turbinate,  for 
doing  which  the  inferior  turbinate  is  cut  away  from  its  attachment  for 
about  an  inch  with  the  scissors  and  then  infracted  over  against  the 
septum  (Fig.  148).  By  needle  puncture  the  anaesthetic  is  injected 
nto  the  antrum.  After  waiting  about  10  minutes,  puncture  the  nasal 
antral  wall  with  special  chisel  or  forceps  (Fig.  149),  and  remove  all  of 
the  wall  under  the  inferior  turbinate 
with  biting  forceps,  one  pair  of  which 
should  bite  forward  and  another  pair 
backward  (Fig.  150).  The  inferior 
turbinate  is  then  replaced,  and  held  in 
position  with  packing  for  24  hours. 
After  the  reaction  of  the  operation,  the 
patient  can  douche  his  own  antrum, 
though  it  is  rarely  necessary,  as  in 
most  cases  the  cure  is  spontaneous.  A 
few  cases,  however,  on  account  of 
anatomical  variations  or  bone  involve- 
ment, will  not  clear  up,  in  such  the 
antrum  should  be  entered  by  the  ex- 
ternal route,  by  means  of  which  an 
inspection  of  the  whole  interior  of  the 
cavity  is  possible. 

Technique. — Incise  the  mucous 
membrane  in  the  gingivo-labial  fold 
from  the  first  molar  to  the  second  incisor  tooth  down  to  the  bone 
of  the  canine  fossa;  elevate  the  periosteum  to  the  brim  of  the  orbit; 
enter  the  antrum  with  a  curette  at  about  the  center  of  the  fossa, 
and  after  the  removal  of  all  of  the  anterior  bony  wall  (Fig.  151)  the 
entire  antral  membrane  can  be  inspected  and  removed,  and  the  bony 
wall  can  also  be  examined.  The  bony  nasal  antral  wall  should  be 
entirely  removed  without  injury  to   the  nasal  mucosa,   the  inferior 


I'lG.  151. — The  skull  with  anterior 
antral  wall  removed  as  done  in  the  e.x- 
ternal  operation.  It  also  shows  the  re- 
moval of  the  bone  in  the  radical 
(Killian),  frontal  sinus  and  ethmoidal 
cell  operation. 


284 


REGIONAL   SURGERY 


turbinate  bone  being  shelled  out  of  its  covering  membrane,  and  a 
"T "-shaped  incision  be  cut  in  the  mucosa  with  the  cross  forward,  mak- 
ing three  flaps,  one  to  be  placed  as  a  covering  for  the  anterior  edge  of 
the  nasal  opening  and  the  other  two  to  be  placed  respectively  on 
the  roof  and  the  floor  of  the  antrum,  being  held  in  place  with  packing, 
the  end  of  the  gauze  packing  emerging  from  the  anterior  nares.     The 

mouth  wound  should  be  allowed  to 
close  without  sutures.  The  pack- 
ing can  be  removed  from  the  nose 
in  48  hours,  at  which  time  the  flaps 
will  have  become  adherent  to  the 
bone,  the  antrum  now  being  merely 
an  open  recess  of  the  nose  where 
secretion  cannot  accumulate,  and  a 
cure  should  result. 

Frontal  Sinus  Diseases. — About 

93  per  cent,  of  frontal  sinus  disease 

Fig.  152.— Anterior  half  of  the  middle  can  be    Cured   intranasally.     After 

turbinate  has  been  removed  and  the  anterior  removing  as  mUCh  of  the  middle 
ethmoidal'  cells  within  the  dotted  line,  in- 

eluding  part  of  the  frontal  duct  which  should  turbmate    as  necessary   (Fig.    152) 

be  removed  for  drainage  of  the  frontal  sinus.    ^^^^  ^^^  infected  anterior  ethmoidal 

cells  which  regularly  accompany  frontal  disease,  the  uncinate  process 
being  chipped  away  with  Myles'  draw  chisels  (Fig.  153);  also  remove 
the  small  ethmoidal  cells  about  the  frontal  duct,  enlarging  the  duct  by 
taking  away  a  part  of  its  anterior  wall.  The  subsequent  treatment 
consists  of  douching  the  sinus  with  normal  saline  solution  or  filling  it 


1 


ra 


/3 


m 


P'iG.   153. — Myles'  draw  chisels. 


with  Beck's  bismuth  paste  daily,  which  will  promote  better  frontal 
drainage.  In  treating  the  frontal  sinus,  the  ethmoidal  cells  should 
not  be  neglected,  the  sinus  sometimes  clearing  up  after  the  ethmoidal 
cells  have  been  cured  intranasally,  but  when  the  ethmoidals  require  the 
external  operation,  the  procedure  should  also  include  the  frontal  sinus. 


NOSE  285 

Of  the  many  methods  devised  for  reheving  frontal  and  ethmoidal 
diseases  by  an  external  route,  Killian's  has  proven  to  be  the  best. 
Modifications  of  Killian's  operation  have  been  proposed  from  time  to 
time,  such  as  leaving  the  anterior  frontal  wall  for  cosmetic  reasons,  but 
this  is  poor  practice.  If  the  frontal  sinus  is  small,  there  will  not  be  a 
noticeable  deformity,  and  if  the  sinus  is  large,  it  is  impossible  to  be  sure 
of  removing  all  of  the  membrane  from  an  opening  in  the  floor  of  the 
sinus,  the  remaining  portion  causing  sooner  or  later  a  sudden  flare  up 
with  swelling,  oedema  of  the  eyelid,  etc.,  distressing  to  both  the  patient 
and  the  surgeon.  The  resulting  depression  above  the  eyebrow,  due 
to  the  removal  of  the  anterior  frontal  wall,  depending  upon  the  height 
and  depth  of  the  sinus,  is  not  so  disfiguring  as  a  poor  result  in  the 
repair  of  the  incision,  cosmetic  results  depending  largely  upon  perfect 
technical  detail,  while  the  depression  can  be  filled  in  with  paraffin  if 
desired,  although  I  have  never  been  requested  to  use  the  paraffin. 
After-effect  of  the  operation  is  an  anaesthesia  of  the  forehead,  caused  by 
dividing  the  supraorbital  nerve,  which  in  two  or  three  months  gradually 
passes  away.  Diplopia  is  often  mentioned  as  an  unfortunate  sequela. 
This  condition  usually  depends  upon  the  treatment  the  trochlea  re- 
ceives. The  trochlea  can  be  safely  detached  from  the  bone  with  a 
sharp  elevator,  working  from  behind  forward,  with  little  likelihood  of 
injury.  Occasionally  there  may  be  transitory  diplopia.  It  has  been 
my  observation  that  when  a  surgeon  takes  great  care  not  to  detach 
the  trochlea,  he  has  damaged  it  in  endeavoring  to  obtain  more  space, 
at  times  resulting  in  double  vision.  Crust  formation  may  develop  as 
an  intranasal  after-effect  soon  disappearing  except  in  atrophic  noses. 

Indications  are  difficult  to  define,  the  local  symptoms,  blood  count, 
general  symptoms,  and  the  information  revealed  by  the  X-ray  plates 
all  need  to  be  well  considered.  The  external  operation  is  rarely 
indicated  in  truly  acute  cases,  and  then  only  with  an  extension  of  the 
infection  into  the  orbit  or  with  a  marked  rise  of  temperature  or  with 
intracranail  symptoms  appearing.  I  do  not  consider  pain  or  tender- 
ness, no  matter  how  severe,  without  a  sharp  rise  of  temperature,  suf- 
ficient indication  for  opening  an  acutely  infected  sinus,  but  I  deem 
severe  pain  and  extreme  tenderness  with  a  marked  increase  of  tem- 
perature ample  reason  for  operating.  A  differential  blood  count  may 
aid  in  determining  whether  to  wait  or  to  operate.  Necrosis,  pro- 
ducing orbital  abscess  and  fistula,  demands  the  external  route. 

Lesions  of  the  eyelid,  orbit  and  optic  nerve,  produced  by  sinusitis, 
should  be  treated  by  the  external  route  which  is  more  direct  and 


286  REGIONAL    SURGERY 

thorough,  even  though  some  cases  may  recover  by  the  intranasal 
measures. 

Cases,  showing  symptoms  of  intracranial  complications,  a  low 
grade  of  chronic  septic  poisoning,  such  as  rheumatic  pains,  sallow  com- 
plexion, rapid  heart  action,  low  resistance  to  infections,  and  anaemia; 
cases  with  discharge,  headache,  and  tenderness  remaining  after  an 
attempt  at  intranasal  drainage;  cases  reproducing  the  so-called  poly- 
poid tissue;  and  lastly,  cases  needing  intranasal  treatment  for  a  con- 
siderable period  and  patients  who  from  nervous  temperament  or  lack 
of  time  prefer  a  more  rapid  method  by  choice;  in  all  such  the  external 
operation  should  be  considered.  The  results  in  the  same  class  of  cases 
should  be  more  satisfactory  with  Killian's  method  as  it  exposes  to 
direct  vision  more  of  the  cavities  and  their  relations  than  does  any  other 
method  and  is  probably  safer,  if  the  truth  were  known,  but  unfortu- 
nately accounts  of  the  fatal  cases  from  intranasal  operations  upon  the 
sinus  are  rarely  published. 

Technique. — First,  make  several  cross  cuts  by  which,  later,  the 
wound  can  be  more  accurately  closed.  The  incision  starts  well  up  on 
the  side  of  the  nose,  slightly  below  the  level  of  the  inner  canthus  to 
avoid  the  plexus  of  veins  about  the  inner  part  of  the  orbital  brim  and 
because  the  resulting  cicatrix  shows  less  here  than  farther  down  on  the 
nose  and  cheek,  the  incision  extending  upward  into  the  eyebrow  as  far 
externally  as  the  X-ray  plate  reveals  the  sinus  to  extend.  Drive  the 
knife  to  the  bone  and  bring  it  along  until  near  the  eyebrow,  when 
the  pressure  is  eased  up  and  only  the  skin  of  the  eyebrow  is  incised. 
Second,  the  skin  of  the  forehead  is  pulled  upward,  so  that  the  incision 
will  lie  over  the  superior  line  of  the  bony  bridge  that  will  be  made,  and 
here  the  periosteum  is  incised  from  near  the  nasal  bone,  parallel 
with  the  orbital  brim  and  about  3^^  in.  above  it  to  a  point  a  little 
farther  externally  than  the  sinus  is  known  to  extend,  which  outlines 
the  upper  margin  of  the  bony  bridge.  The  periosteum  is  elevated  over 
a  slightly  greater  area  than  the  dimensions  of  the  sinus.  A  pack  of 
gauze,  saturated  with  suprarenal  solution,  is  allowed  to  remain  under  the 
elevated  periosteum  while  the  lower  outline  of  the  bridge  and  the  inner 
boundary  of  the  ethmoidal  exposure  is  made  by  extending  the  previous 
incision  in  the  periosteum  on  the  side  of  the  nose  outward  just  along 
the  orbital  brim,  as  far  as  the  floor  of  the  sinus  is  suspected  to  extend. 
Elevate  the  periosteum  first  at  the  lower  end  of  the  incision  where  it  is 
easily  detached  and  carried  backward  until  the  lachrymal  groove  is 
fully  exposed;  then  the  orbital  periosteum  is  elevated  just  above  the 


NOSE  287 

groove,  backward,  an  inch  or  more,  until  the  anterior  ethmoidal  vessels 
are  felt.  Carry  the  elevator  upward  behind  the  attachment  of  the 
trochlea,  which  is  detached  from  the  bone  with  the  edge  of  a  sharp 
curette  from  behind  forward.  All  this  is  done  under  the  disadvantages 
of  an  annoying  hemorrhage.  Pack  the  cavity  with  gauze,  saturated 
with  suprarenal  solution  and  return  to  the  anterior  wall  of  the  frontal 
sinus.     The  hemorrhage  here  will  have  ceased  and  the  anterior  bony 


Fig.  154. — Cosmetic  result  after  Killian's  operation.  Right  side.  The  line  of  the 
incision  is  along  side  of  the  nose  and  in  eye-brow,  and  is  almost  invisible.  It  was  a  medium- 
sized  sinus.     Note  the  slight  depression  abov^e  the  eye-brow. 

wall  is  removed,  first  by  outHning  the  bony  bridge  with  Killian's  V- 
shaped  chisel,  and  second  by  removing  the  entire  anterior  wall,  searching 
carefully  until  all  the  recesses  have  been  uncovered  and  the  lining  mem- 
brane removed  from  every  part  of  the  sinus.  Special  care  should  be 
given  to  the  posterior  side  of  the  bridge  and  the  lower  and  inner  part  of 
the  sinus.  Now  go  below  and  make  the  bony  grooves  that  will  outHne  the 
bridge  and  the  ethmoidal  route,  first  making  a  groove  in  the  nasal  process 


288 


REGIONAL   SURGERY 


of  the  superior  maxilla  from  the  nasal  articulation  to  the  lachrymal 
groove  from  before  backward  across  the  grain  of  the  bone;  then  start  a 
groove  at  right  angles  to  this  cross  groove,  upward  along  the  articulation 
of  the  nasal  bone  and  nasal  process  of  the  maxilla,  then  outward  along  the 
lower  edge  of  the  orbital  brim  as  far  as  the  floor  of  the  sinus  extends. 
Remove  this  shell  of  bone  with  chisel  and  forceps,  exposing  the  lower 
part  of  the  frontal  sinus,  fronto-nasal  duct  and  anterior  ethmoidal  cells. 
The  bony  orbital  wall  is  removed  as  far  as  it  is  in  relation  to  the  frontal 
sinus  and  to  the  ethmoidal  cells,  as  far  back  as  the  anterior  ethmoidal 
vessels,  not  only  to  give  access  to  the  deeper  cells,  but  also  to  give  a 
perfectly  healthy  external  surface  to  what  was  the  ethmoidal  labyrinth. 
About  an  inch  in,  the  anterior  ethmoidal  vessels  will  be  encountered, 
emerging  from  the  orbit  into  the  superior  part  of  the  ethmoidal  cells. 
Occasionally  an  ethmoidal  cell  is  found  wrapped  around  these  vessels, 
and  its  removal  requires  great  care  not  to  wound  the  vessels.  The  in- 
fected ethmoidal  cells  should  be  entirely  removed,  not  simply  curetted. 
If  the  sphenoidal  sinus  is  diseased,  it  is  entered,  and  the  anterior  wall 
is  removed,  the  balance  of  the  treatment  being  done  better  afterward. 

Gauze  is  lightly  packed  along  the 
operative  track  and  brought  out  of 
the  nose,  and  finally  the  wound  is 
accurately  closed  with  metal  clips, 
and  a  wet  boric  dressing  is  applied 
like  the  padding  of  a  saddle,  so  that 
there  will  be  no  pressure  upon  the 
incision  and  the  bridge,  the  gauze 
and  clips  being  removed  in  24  hours. 
This  procedure,  like  the  radical 
mastoid  operation,  for  success  de- 
pends mainly  on  perfect  technical 
detail,  portions  of  the  membrane 
or  a  few  small  ethmoidal  cells  left 


Fig.  155. — The  dotted  line  shows  the 
amount  of  the  middle  turbinate  that  has 
been  removed  to  gain  access  to  the  sphe- 
noidal wall.    The  dark  portion  of  the  anterior 

sphenoidal  wall  illustrates  the  portion  that  behind  spellmg  failure,  and  a  care- 


and    closing    of    the 


has  been  removed.  1   ^^     ^^^„;„„ 

less    openmg 

incision  meaning  disfigurement  (Fig.   154). 

After -treatment. — The  less  the  better.  A  little  ointment,  such  as 
bismuth  paste  in  the  nostril  several  times  a  day  is  about  all  that  is 
necessary.     Watch  the  case  closely  and  do  little. 

The  sphenoidal  sinus  is  usually  associated  with  posterior  ethmoidal 
disease.     To  gain  access  to  the  sinus  (Fig.  155),  theposteriorhalf  of  the 


NOSE  289 

middle  turbinate  has  to  be  removed  and  then  the  anterior  sphenoidal 
wall  comes  into  view.  The  sphenoidal  ostium  is  entered  with  a  curette 
or  forceps  and  as  much  of  the  anterior  wall  removed  as  possible.  The 
lining  membrane  should  be  attacked  with  great  caution  because  of  the 
important  structures  in  relation  to  this  sinus,  and  when  possible,  it  is 
better  let  alone. 


SECTION  XVI 
SURGERY  OF  THE  EAR 

By 
MAX  A.  GOLDSTEIN,  M.  D., 

St.  Louis,  ]Mo. 

Within  the  past  two  decades  otology  has  advanced  to  the  distinction 
of  a  dignified  special  field  in  surgery  owing  to  its  emancipation  from 
empirical  and  obsolete  practices  to  which  it  had  been  enslaved  for  half  a 
century. 

The  practice  of  surgery  of  the  ear  should  be  based  on  the  same 
sound  and  sane  surgical  principles  as  those  employed  in  general  surgical 
practice.  Inflammatory  processes  localized  in  the  ear  depend  on 
infectious  foci  and  these  should  be  sought  for  and  surgically  dealt 
with  wherever  possible;  free  incision  of  a  circumscribed  inflammation 
in  the  auditory  canal  or  in  the  membrana  tympani,  should  be  utilized 
rather  than  small  punctures  with  inefficient  instruments,  old-fashioned 
dressings,  poultices  and  washes. 

Drainage  is  as  vital  a  feature  of  success  to  ear  surgery  as  it  is  to  the 
surgery  of  any  other  part  of  the  body;  unfortunately  the  deeper  struc- 
tures of  the  ear  are  often  difficult  of  inspection  and  of  access  and 
this  offers  additional  handicaps  to  effective  work.  Reforms  in  oto- 
logical  practice  have  been  numerous  and  will  be  considered  minutely 
in  their  respective  chapters.  The  keynote  of  this  volume  is  practical 
surgery  and  we  will  endeavor  in  this  section  on  otology  to  eliminate  all 
empiricism,  unnecessary  anatomical  and  physiological  details,  biblio- 
graphical data  and  elaborate  illustrations.  This  will  necessitate  the 
omission  of  much  pathological  discussion  and  many  therapeutic  sug- 
gestions to  be  found  in  the  usual  text  books  on  otology, 

CLASSIFICATION 

For  convenient  practical  and  clinical  classification  we  recognize 
three    subdivisions:  (i)   the  external  ear;   (2)   the  MmDLE  ear; 

(3)  THE  INTERNAL  EAR. 

291 


292  REGIONAL    SURGERY 

The  External  Ear.— The  external  ear  includes  the  cartilaginous 
structure  of  the  auricle  with  its  various  ridges  and  fossae  and  its  ex- 
tension inwards  forming  the  external  auditory  canal,  tortuous  and 
hour  glass  in  shape  in  its  cartilaginous  portion  and  terminating  at  its 
distal  end  in  the  annulus  tympanicus  in  which  the  membrana  tympani 
is  spanned.  The  auricle,  composed  largely  of  elastic  cartilage,  is 
continued  as  the  external  two-thirds  of  the  external  auditory  canal  and 
is  covered  with  a  rather  thin  integument,  contains  comparatively  few 
of  the  glandular  elements  of  the  skin  and  has  a  very  limited  vascu- 
lar nourishment.  This  limited  vascular  nourishment  and  the  close 
adhesion  of  the  thin  layer  of  skin  to  the  perichondrium,  makes  the 
external  ear  intensely  susceptible  to  acute  pain  with  only  the  smallest 
focus  of  infection. 

Funinculosis. — A  furuncle  of  insignificant  size,  when  occurring 
in  the  skin  of  the  auricle  or  of  the  external  auditory  canal,  may  produce 
excruciating  pain  because  of  the  active  tension  on  the  surrounding 
tissues.  An  infectious  focus  of  so  slight  a  character  in  any  other  part 
of  the  integument  where  more  elasticity  and  looseness  exists  would  be 
unnoticed.  An  intense  pain  in  the  meatus  of  the  auditory  canal  may 
produce  so  slight  a  macroscopic  change  to  the  eye  of  the  otologist 
that  he  is  prone  to  underrate  the  pain  and  discomfort  of  which  the 
patient  complains.  The  site  of  infection  may  be  even  overlooked 
during  an  examination  when  the  otologist  passes  a  speculum  into  the 
auditory  canal  and  covers  the  focus  of  infection  from  view.  Only 
by  the  patient's  repeated  wincing  when  the  pressure  of  the  speculum 
over  the  sensitive  part  becomes  unbearable  is  the  observer's  attention 
called  to  the  fact  that  some  small  infected  hair-follicle  or  cerumen 
gland,  has  escaped  him. 

In  the  external  auditory  canal  a  more  extensive  form  of  dermal 
and  cellular  infection  is  possible  because  of  the  larger  size  and  depth 
of  the  follicles  contained  therein.  These  are  the  hair-follicles  from 
which  spring  the  vibrissae  that  protect  the  auditory  canal  from  the 
invasion  of  dust,  small  insects  and  other  foreign  particles,  and  the 
group  of  cerumen  glands  located  in  the  external  third  of  the  canal  and 
just  beyond  the  meatus.  These  cerumen  glands  often  have  a  very 
deep  and  winding  course  and  extend  to  the  lowest  layers  of  the  skin 
and  underlying  subcutaneous  tissues.  Infection  of  such  a  deep  hair- 
follicle  or  cerumen  gland  may  become  so  intense  that  a  marked  in- 
filtration or  induration  of  this  part  of  the  auditory  canal  ensues  and  the 
entire  lumen  of  the  auditory  canal  may  be  temporarily  closed  thereby. 


SURGERY   OF   THE   EAR  293 

-  Furunculosis  of  the  auricle,  or  as  it  is  more  commonly  prevalent, 
of  the  external  auditory  canal,  is  not  only  a  very  painful  condition  to  the 
patient  but  often  a  very  troublesome  affection  for  the  otologist.  If 
furunculosis  always  occurred  in  an  isolated  follicle  and  was  self-limiting 
in  character,  it  would  not  deserve  so  close  a  consideration,  but  it 
often  affects  groups  of  follicles;  patients  who  have  contracted  one 
infection  of  this  character  are  peculiarly  susceptible  to  recurrences  and 
re-infections. 

The  most  effective  treatment  for  furunculosis  is  free  incision,  a 
careful  cleansing  of  the  exudate  and  pus  from  the  auditory  canal, 
and  an  antiseptic  dressing  in  the  canal  to  prevent  further  infection. 
When  additional  follicles  are  attacked  and  the  process  continues, 
either  autogenous  vaccines  or  stock  vaccines  prepared  from  the  pus 
producers  found  in  this  class  of  infections  will  be  of  inestimable  value 
as  a  therapeutic  measure. 

My  usual  procedure  in  the  treatment  of  furunculosis  auris  is  as 
follows:  If  seen  in  its  incipient  state  the  surface  of  the  furuncle  may 
be  washed  with  a  swab  of  98  per  cent,  alcohol  and  painted  with  tincture 
of  iodine.  In  twenty-four  to  forty-eight  hours  the  pain  and  inflam- 
matory character  of  this  localized  infection  will  either  have  ceased  or 
become  so  aggravated  and  sensitive  that  incision  with  a  small  furuncle 
knife  is  called  for.  The  incision  should  be  made  through  the  furuncle 
to  the  depth  of  the  follicle  and  the  slight  bleeding  that  follows  should 
be  encouraged.  If  pus  has  already  formed  I  find  it  practical  to  take  a 
large-sized  Gruber  speculum  and  press  firmly  around  the  edge  of  the 
incision  to  evacuate  the  contents  of  the  infected  follicle.  The  exudate 
and  blood  should  be  washed  out  of  the  auditory  canal  with  a  warm 
1 :  2000  bichloride  or  2  per  cent,  carbolic  acid  solution,  or  mopped  out 
with  pure  alcohol.  The  canal  is  then  dried  and  a  small  gauze  strip 
saturated  with  20  per  cent,  carbolized  gylcerin,  is  lightly  packed  into 
the  auditory  canal  beyond  the  area  of  infection.  The  dressing  is 
changed  in  12  hours,  the  parts  inspected  for  possible  freshly-infected 
follicles  and  a  similar  gauze  strip  inserted. 

A  free  purge  is  prescribed  when  the  patient  is  first  seen  and  all  of 
the  eliminating  organs  stimulated  to  full  capacity. 

In  protracted  cases  vaccines  have  frequently  been  very  effective  in 
my  hands  when  other  measures  have  failed.  Stock  furunculosis 
vaccines,  or  as  it  is  more  familiarly  known  as  furunculosis  bacterin, 
composed  of  the  various  pus  producing  organisms,  isolated  from  boils 
and  carbuncles,  is  used  as  follows:  initial  dose  should  not  exceed  100 


294  REGIONAL   SURGERY 

to  150  millions;  within  five  days  a  second  dose  of  200  to  250  millions 
may  be  given;  the  third  dose  five  days  later  may  be  increased  to  300 
or  400  millions.  I  have  never  found  it  necessary  to  use  more  than 
four  such  doses.  Vaccine  is  administered  subcutaneously  by  hypo- 
dermatic syringe  in  the  usual  manner  and  I  have  never  yet  seen  any 
untoward  results  when  these  conditions  are  carefully  complied  with. 

When  the  infectious  condition  has  subsided  and  the  skin  of  the 
auditory  canal  has  cleared  up,  it  will  often  be  found  necessary  to  lubri- 
cate the  surface  of  the  auditory  canal  with  a  little  simple  ointment,  to 
prevent  a  dry,  scaly  eczema  that  frequently  ensues. 

DIFFUSE   INFLAMMATION 

The  above  procedure  may  be  applied  not  only  to  localized  furuncu- 
losis  of  the  external  auditory  canal  or  auricle  but  also  to  a  more  diffuse 
inflammation  or  cellulitis  affecting  these  areas.  Here  more  liberal 
and  more  frequent  incision  may  be  necessary  and  frequent  changings 
of  dressings ;  it  may  even  be  found  necessary  and  will  do  much  to  alle- 
viate pain,  to  order  the  patient  to  bed  and  direct  a  constant  douching 
of  the  auditory  canal  with  half  of  i  per  cent,  lysol  in  water  at  a  tem- 
perature of  110°  to  ii5°F.,  and  repeating  this  douching  with  quantities 
varying  from  i  pint  to  i  gallon  as  often  as  is  thought  advisable  for  the 
relief  of  pain  and  congestion  and  to  carry  off  the  waste  products  exuded 
in  the  ear. 

Ot-Haematoma. — Wrestlers,  boxers,  football  players  and  other 
athletes  are  frequently  subject  to  rough  handling  about  the  auricle 
and  the  hemorrhage  from  some  little  capillary  may  cause  a  marked 
effusion  of  blood  under  the  skin  of  the  auricle;  they  may  become  more 
or  less  organized  in  irregular  clumps  or  masses,  permitting  the  so-called 
ot-haematoma.  These  blood  clots  should  be  carefully  evulsed  after 
incision  with  a  sharp  scalpel  in  the  least  conspicuous  part  of  the  surface 
of  the  auricle  in  which  they  are  found;  the  surface  should  be  painted 
with  iodine  and  a  collodion  dressing  applied  to  prevent  infection  during 
healing. 

Frost-bite. — The  old  idea  to  rub  a  frost-bitten  ear  with  snow  or  ice 
to  save  it  from  further  trouble,  is  based  on  many  years  of  experience 
by  the  layman  with  this  class  of  cases.  In  a  frost-bitten  ear  in  which  the 
circulation  has  been  temporarily  arrested  and  a  localized  gangrene  may 
be  imminent,  experience  has  proven  a  valuable  teacher  in  formulating 
the  above  customary  procedure.  Frost- bite  should  be  treated  very 
much  like  a  burn,  for  they  both  depend  on  arrested  circulation  and 


SURGERY  OF   THE   EAR  •  295 

surface  destruction  of  the  involved  areas.  As  the  external  ear  is  poorly- 
supplied  with  blood-vessels,  a  too  active  interference  or  disturbance  of 
these  crippled  tissues  must  not  be  indulged  in.  A  frost-bitten  ear  should 
be  treated  very  much  like  a  burn  of  the  second  degree;  the  parts  should 
be  kept  thoroughly  at  rest;  if  the  skin  is  broken  or  blistered,  cam- 
phorated oil,  or  even  crude  petroleum  may  be  found  a  very  effective 
dressing. 

Foreign  Bodies  in  the  External  Auditory  Canal. — Foreign  bodies  in 
the  external  auditory  canal  may  be  of  many  varieties,  viz. :  animate  or 
inanimate,  rough  or  smooth,  cereal  and  soft,  or  stony  and  hard;  vege- 
table, mineral,  or  animal  in  character.  The  character  and  variation 
in  the  methods  of  removing  a  foreign  body  from  the  auditory  canal 
depend  largely  on  its  character  and  consistency. 

If  a  live  insect  finds  its  way  into  the  auditory  canal  the  first  and 
safest  step  is  to  kill  it  before  removing  it  from  the  ear.  Small  insects 
that  reach  the  fundus  of  the  auditory  canal  may  do  considerable  damage 
by  moving  over  the  surface  of  the  membrana  tympani  and  bruising  or 
tearing  it  in  their  struggle  to  get  away.  A  few  drops  of  chloroform 
instilled  into  the  auditory  canal,  with  the  affected  ear  uppermost  so 
that  the  chloroform  may  reach  the  surface  of  the  drum  membrane,  is 
the  quickest  and  most  effective  way  of  killing  a  living  insect.  Such  an 
insect  may  then  be  dealt  with  as  any  ordinary  foreign  body  and  syringed 
out,  or  removed  with  the  forceps,  if  practical. 

A  small  bean,  grain  of  corn  or  other  cereal  that  has  found  its  way  into 
the  auditory  canal,  should  be  removed  without  the  use  of  water  or  other 
aqueous  solution.  When  I  was  an  undergraduate  in  medicine  and  the 
class  in  the  dissecting  room  had  finished  its  work  on  the  "subject" 
and  lots  had  been  drawn  for  the  skeleton,  much  time  was  spent  in  a 
careful  cleansing  of  the  bones.  The  difficulties  in  disarticulating  the 
skull  were  easily  surmounted  by  packing  the  entire  skull  cavity  through 
the  foramen  magnum  with  dry  navy  beans  and  throwing  it  into  a  bucket 
of  water  over  night.  The  next  morning  the  swelling  of  the  beans  by  the 
absorption  of  water,  had  produced  sufficient  pressure  to  beautifully 
disarticulate  the  skull  without  further  effort. 

This,  in  miniature  form,  is  what  takes  place  when  a  single  navy  bean 
or  other  cereal,  lodged  in  the  auditory  canal,  is  subjected  to  a  soaking 
process  by  any  watery  solution.  The  auditory  canal  is  tortuous  and 
hour  glass  in  shape,  and  if  the  long  axis  of  the  bean  happens  to  be  in  the 
narrowest  diameter  of  the  canal,  the  swelling  of  said  bean  may  wedge 
it  tightly  in  this  spot  and  make  it  extremely  difficult  of  removal. 


296  REGIONAL   SURGERY 

For  the  removal  of  cereal  foreign  bodies,  therefore,  we  may  employ 
one  of  several  forms  of  foreign  body  hooks,  forceps,  or  spoons. 

Much  difficulty  is  encountered  when  a  foreign  body  is  smooth,  hard 
and  round,  such  as  a  glass  bead,  pebble,  shoe-button  without  the  eyelet, 
etc.  If  such  foreign  bodies  have  been  tampered  with  before  they  are 
brought  to  the  doctor,  it  is  very  likely  that  the  fond  parent  or  other  well- 
wisher  has  succeeded  in  pushing  the  mass  into  the  bony  part  of  the 
auditory  canal  by  means  of  hairpins,  or  other  home-made  surgical 
apparatus. 

It  is  advisable'and  justifiable  in  many  of  these  cases,  especially  in 
young  nervous  children,  to  administer  a  general  anaesthetic  so  as  to 
permit  the  operator  to  deliberately  examine  the  canal  and  to  remove  the 
foreign  body  under  good  illumination. 

In  otology  illumination  is  a  more  important  consideration  than  when 
applied  to  any  other  cavity  of  the  body,  for  it  is  difficult  at  best  to  see 
all  of  the  various  landmarks  in  the  ear,  and  a  good  source  of  light  and 
the  proper  use  of  the^head-reflector,  is  of  vital  importance. 

The  most  common  form  of  foreign  body  in  the  ear  is  inspissated  or 
impacted  cerumen.  When  inspissated  and  of  soft  consistency,  such  a 
mass  of  cerumen  may  be  readily  washed  out  of  the  auditory  canal  by 
means  of  an  ear  syringe  and  alkalinized  water.  A  scant  teaspoonful 
of  borax  or  soda  in  half  a  pint  of  warm  water,  will  sufficiently  soften  and 
saponify  the  usual  inspissated  mass  of  cerumen.  If,  on  inspection,  such 
a  mass  of  cerumen  is  found  to  be  extremely  hard  to  the  touch  of  the 
probe,  additional  precaution  should  be  taken  to  direct  the  patient  to 
soak  it  thoroughly  three  or  four  times  during  24  hours  before  the 
removal,  with  the  following  solution: 

I^.  Sod.  Bicarbonat gr.  xv 

Glycerini 3  » 

•  Aq.  Destil 5" 

This  should  be  instilled  warm  into  the  ear  three  or  four  times  in  the 
24  hours  preceding  the  use  of  the  syringe.  It  will  then  be  found  that 
the  hardened  mass  of  cerumen  has  been  sufficiently  softened  to  permit 
the  pressure  of  the  current  of  fluid  to  wash  it  out  of  the  canal  safely. 

The  Use  of  the  Ear  Syringe. — A  few  words  about  the  proper  use  of 
the  ear  syringe  may  not  be  amiss. 

The  tortuous  character  of  the  cartilaginous  external  auditory  canal, 
the  pecuhar  plane  which  the  drum  membrane  makes  with  the  floor  and 
walls  of  the  canal  and  the  sensitive  and  delicate  structure  of  the  drum 


SURGERY   OF   THE   EAR  297 

membrane  all  require  some  consideration  when  a  current  of  fluid  is 
projected  with  more  or  less  force  from  a  syringe  into  the  fundus  of 
the  canal  for  the  purpose  of  removing  a  foreign  body.  The  accompany- 
ing illustration  diagrammatically  emphasizes  this  point  (Fig.  156). 

If  fluid  is  projected  from  a  syringe  straight  to  the  fundus  or  along  the 
floor  of  the  canal,  it  impinges  with  too  much  force  at  the  acute  angle 
that  the  membrana  tympani  makes  with  the  floor  of  the  canal  and  is 
likely  to  cause  considerable  mechanical  damage,  actual  pain  and  in 
some  instances  even  rupture  of  the  delicate  membrane.  The  char- 
acteristic procedure  for  this  simple  technique  is  to  straighten  the  tortuous 
auditory  canal  by  pulling  the  auricle  upward  and  backward  and  point- 
ing the  tip  of  the  syringe  in  a  long  angle  toward  the  superior  wall  of 
the  auditory  canal.  This  ensures  the  current  of  fluid  passing  above  the 
foreign  body,  impinging  on  the  plane  of  the  drum  membrane  at  its 
least  susceptible  obtuse  angle  and  reflecting  the  return  current  in  this 
way  toward  the  floor  of  the  canal  and  by  this  pressure  from  behind  the 


o 


Fig.  156. — The  aural  douche. 

foreign  body  washing  same  out  of  the  canal  with  the  least  possible 
mechanical  force. 

It  is  an  established  axiom  that  any  fluids  used  in  the  ear  should 
always  be  used  "warm.  There  is  no  exception  to  this  rule  in  otological 
therapy. 

Tumors  of  the  External  Ear. — Tumors  of  the  auricle  and  neoplasms 
of  the  external  auditory  canal  should  be  treated  as  in  other  areas  of  the 
skin.  Keloids,  fibromata,  papillomata,  carcinomata,  exostoses,  hema- 
tomata,  are  the  tumors  of  most  frequent  occurrence  in  the  external 
ear. 

Skin  Lesions. — Eczema  of  the  external  auditory  canal  and  auricle 
are  of  quite  frequent  occurrence.  Among  the  most  usual  irritating 
causes  may  be  mentioned  neglected  discharges  from  the  ear  in  children; 
picking  the  auditory  canal  with  the  end  of  a  toothpick,  match,  lead  pencil, 
hat  pin,  or  even  dirty  finger  nail;  the  absence  of  cerumen  which  acts 
as  a  natural  lubricant  to  the  surface  of  the  canal,  or  the  extension 


298  REGIONAL   SURGERY 

by  continuity  of  surface  of  an  eczematous  process  over  the  auricle 
into  the  external  auditory  canal. 

In  the  case  of  children  with  a  suppurative  otitis  media  attention 
should  be  directed  to  the  tendency  of  the  child  to  put  its  finger  into  the 
ear  and  carry  the  pus-laden  finger  to  the  eye,  scalp,  nose,  lips,  or  other 
parts  of  the  head  and  thereby  producing  a  similar  infection  there. 

The  local  treatment  of  eczema  in  the  ear  is  rather  more  difficult  and 
stubborn  than  in  other  areas  of  the  skin  because  it  is  difficult  to  apply  an 
ointment  or  a  lotion  in  a  canal  of  such  small  diameter  and  the  reaction 
is  often  inadequate  because  of  the  poorly  nourished  skin. 

For  eczema  auris  Ung.  Hydrarg.  Ox.  Flav.,  with  equal  parts  of  Adeps 
Lanag,  may  be  found  of  much  value;  or  Ung.  Plumbi.,  where  consider- 
able itching  is  a  symptom;  or  5  per  cent.  Resorcin  in  Ung.  Petrolati 
may  prove  effective. 

The  Middle  Ear. — The  anatomical  and  physical  relationship  of  the 
tympanic  cavity  and  its  accessory  areas  is  the  foundation  on  which  the 
entire  pathology  and  therapy  of  diseases  of  the  middle  ear  is  based.  The 
tympanic  cavity  is  but  a  small  irregularly  shaped  cuboidal  space  of 
about  the  contents  of  8  to  10  drops  of  water.  Normally  it  is  in  direct 
communication  through  the  Eustachian  tube  with  the  nasopharynx, 
fined  with  a  contiguous  mucous  membrane,  and  therefore  may  be 
logically  and  anatomically  regarded  as  a  part  of  the  upper  respiratory 
tract. 

It  is  this  very  continuity  of  surface  of  the  mucous  membrane  from 
the  nose  and  nasopharynx  through  the  Eustachian  tube  to  the  tympanic 
cavity  proper,  the  additus  ad.,  antrum,  and  ramification  of  mastoid 
cells  that  makes  this  series  of  small  bone  cavities  constituting  the 
middle  ear  an  area  of  tremendous  susceptibility  to  all  forms  of  in- 
flammatory and  infectious  processes. 

This  continuity  of  mucous  surface  in  an  area  of  liberal  vascular  and 
lymphatic  supply  is  responsible  for  the  frequent  participation  of  the 
middle-ear  cavity  in  inflammations,  suppurations  and  other  pathologi- 
cal changes  occurring  in  the  wake  of  various  exanthemata.  The 
eruptive  fevers  all  have  their  origin  of  infection  in  the  tonsils  and  fauces, 
and  the  close  juxtaposition  of  the  pharyngeal  mouth  of  the  Eustachian 
tube  and  direct  extension  through  the  tube  to  the  tympanic  cavity 
develops  similar  processes  of  infection  in  the  mucosa  of  the  tympanic 
cavity.  Bacteriologically  we  can  demonstrate,  from  the  pus  in  the 
external  auditory  canal  that  finds  its  vent  through  the  perforation  of 
the  drum  membrane,  the  streptococcus,  Klebs-Loeffler  bacillus,  the 


SURGERY   OF   THE   EAR  299 

various  pus-producing  microorganisms,  and  even  in  rare  instances  such 
an  unusual  invasion  as  that  of  actinomycosis  into  the  tympanic  cavity. 

Mechanically  the  relationship  of  the  Eustachian  tube  and  naso- 
pharyngeal structures  is  an  equally  important  factor  in  the  production 
of  affections  of  the  middle-ear  cavity.  Twenty-five  years  ago  the  cause 
of  15  to  20  per  cent,  of  acquired  deafness  in  children  in  institutions  for 
the  deaf  all  over  the  world  could  be  traced  to  excessive  adenoid  vege- 
tations. In  the  most  aggravated  forms  adenoid  tissue  had  grown  into 
the  pharyngeal  mouth  of  the  Eustachian  tube,  obliterated  the  caliber 
of  the  tube,  prevented  the  ventilation  of  the  tympanic  cavity,  caused 
collapse  of  the  membrana  tympani,  until  its  mucous  surface  had  formed 
adhesions  to  the  promontory  and  produced  a  serious  mechanical  t}pe 
of  deafness. 

Since  the  discovery  of  the  pathology  of  adenoid  vegetations  and  the 
accepted  surgical  disposal  of  this  tissue,  the  large  percentage  of  acquired 
deafness  has  been  greatly  reduced.  Today  the  pathology  and  surgery 
of  the  tympanic  cavity  and  its  accessory  areas  is  based  on  a  healthy 
comprehension  and  mastery  of  technique  in  the  disposal  of  these 
affections. 

DISEASES  OF  THE  TYMPANIC  CAVITY 

The  diseases  of  the  tympanic  cavity  have  been  empirically  divided 
into  two  groups:  (a)  suppurative  otitis  media;  (b)  catarrhal  or  non- 
suppurative otitis  media. 

Chronologically  these  two  groups  are  again  divided  into  acute,  sub- 
acute, and  chronic  affections,  the  time  limit  constituting  to  a  large 
extent  the  period  of  division. 

Ear-ache. — Acute  catarrhal  or  non-suppurative  otitis  media,  or  its 
more  commonly  known  ear-ache,  is  usually  a  condition  associated  with 
an  acute  hyperemia  or  inflammation  of  some  area  of  the  upper  respira- 
tory tract  in  direct  relation  or  continuity  with  the  tympanic  cavdty.  A 
small  percentage  of  cases  of  acute  otitis  media  may  also  be  developed 
from  a  direct  exposure  to  cold  attacking  the  membrana  tympani  exter- 
nally through  the  auditory  canal. 

The  symptom  which  first  brings  us  into  contact  with  our  patient  is 
pain,  varying  in  character,  frequently  coming  on  suddenly  and  rapidly 
increasing  in  intensity.  Pain  is  especially  aggravated  in  the  case  of 
children  and  is  frequently  accompanied  by  fever,  delirium  and  intense 
nervous  excitability.     On  examination  of  the  ear  the  drum-membrane 


300  REGIONAL   SURGERY 

presents  an  intensely  hyperemic  picture  indicative  of  acute  inflamma- 
tory reaction.  If  seen  within  a  few  hours  the  first  change  in  the  drum- 
membrane  noticeable  is  a  retraction  of  the  plane  inward  due  to  a  dimin- 
ished air  supply  through  the  tympanic  cavity  by  the  narrowing  of 
the  caHber  of  the  Eustachian  tube  with  the  onset  of  the  inflammation. 
Now  follows  the  exudation  of  serum  or  mucus  into  the  tympanic  cav- 
ity. The  accumulated  contents,  when  the  capacity  of  the  tympanic 
cavity  is  reached,  bulges  the  membrane  outward,  the  convexity  depend- 
ing on  the  quantity  of  fluid  contained  within  the  cavity  and  the  pressure 
that  is  brought  to  bear  on  the  membrana  tympani. 

When  inspection  reveals  this  intense  convexity  of  the  membrana 
tympani  with  a  red,  deeply  injected  surface  appearance,  paracentesis  is 
emphatically  and  always  indicated,  the  object  of  this  incision  being  to 
relieve  the  middle-ear  cavity  of  its  pent-up  fluid  contents  and  inflam- 
matory products,  and  also  to  save  the  drum-mem- 
brane from  a  spontaneous  natural  rupture  which 
takes  place  as  soon  as  the  pressure  exerted  by  the 
fluid  can  overcome  the  resistance  of  the  delicate 
membrane.     With  this  incision  of  the  drum-mem- 
brane we  release  the  fluid  from  the  middle-ear 
cavity,  relieve  the  pressure  and  hence  the  pain, 
and    save    the   drum-membrane  from  a  ragged. 
Fig.  is?.— Myringot-    irregular  perforation.     An  incision  of  this  elastic 

omy.  A,  Line  of  in-  tissue  invariably  heals  in  a  short  time  if  the  proc- 
cision  in  the  drum  head. 

ess  does  not  go  on  to  suppuration. 

The  location  and  character  of  an  incision  of  the  ear  drum  is  best 
indicated  in  the  accompanying  illustration  (Fig.  157). 

The  middle  layer  of  the  membrana  tympani  is  histologically  com- 
posed of  two  sets  of  elastic  fibers:  {a)  radiating  fibers  from  the  manu- 
brium to  the  periphery;  (b)  circular  fibers,  ranged  parallel  with  the 
annulus  tympanicus.  These  two  sets  of  fibers  have  as  their  function 
the  maintenance  of  tension  of  the  membrana  tympani.  If,  therefore, 
we  desire  by  our  incision  to  effect  satisfactory  drainage  of  the  fluid 
contents  from  the  middle-ear  cavity,  and  at  the  same  time  wish  to  con- 
serve the  further  function  of  the  drum-membrane,  the  area  of  incision 
should  be  made  where  the  fewest  of  these  fibers  may  be  injured. 

The  membrana  tympani  is  divided  topographically  into  four  quad- 
rants: one  imaginary  hne  crosses  horizontally  with  the  manubrium  as 
the  diameter;  the  second  line  is  a  perpendicular  to  the  first  line  bisecting 
the  manubrium.     These  two  lines  divide  the  membrana  tympani  into 


SURGERY    OF    THE    EAR  3OI 

four  quadrants:  (i)  anterior  superior  quadrant;  (2)  anterior  inferior 
quadrant;  (3)  posterior  superior  quadrant;  and  (4)  posterior  inferior 
quadrant  (Fig.  158). 

Our  line  of  incision  extends  from  a  point  in  the  lower  part  of  the 
superior  posterior  quadrant  near  the  periphery  of  the  drum-membrane 
and  sweeps  down  to  the  floor  of  the  membrana  tympani. 

The  floor  of  the  tympanic  cavity  lies  lower  than  the  floor  of  the 
external  auditory  canal  at  its  juxtaposition  with  the  tympanic  cavity. 
It  is,  therefore,  necessary,  in  order  to  insure  adequate  drainage,  that  our 
incision  extend  well  down  to  the  floor  of  the  external  auditory  canal. 


Fig,  158. — The  dark  areas  represent  perforations  and  the  figures  express  the  relative 
frequency  of  perforations  in  the  corresponding  locaUties  of  the  membrana  tympani  based 
on  1000  cases.  6,  100,  Perforations  in  Shrapnell's  membrane;  164,  perforation  at  the 
incudostapedial  articulation;  56,  perforation  near  tympanic  orifice  of  Eustachian  tube; 
3,  12,  16,  perforations  near  annelus;  14,  perforation  at  neck  of  malleus;  372,  perforation 
in  post.  inf.  quadrant;  257,  perforation  in  antero-inf.  quadrant.     {Adapted  frotn  Randall.) 

Observation  will  corroborate  the  cHnical  fact  that  the  higher  the 
location  of  a  perforation  in  the  drum-membrane  the  longer  the  duration 
of  the  suppuration  and  the  less  adequate  the  drainage;  the  lower  the 
perforation  in  the  drum-membrane  the  shorter  is  the  duration  of  sup- 
puration and  the  more  satisfactory  the  drainage.  This  is  a  simple 
mechanical  as  well  as  surgical  principle. 

To  incise  the  drum-membrane  satisfactorily,  especially  in  children 
who  are  nervous  and  restless,  a  general  ana?sthesia,  preferably  by  gas, 
somnoform  or  ethyl  chloride  is  recommended. 

After  the  incision  the  auditory  canal  should  be  lightly  packed  with  a 
strip  of  sterile  gauze  and  further  protected  by  a  small  pledget  of  cotton 


302  REGIONAL   SURGERY 

in  the  meatus  of  the  canal.  The  source  of  the  infection  in  the  naso- 
pharynx or  pharynx  should  be  carefully  looked  into.  In  acute  coryza 
or  acute  nasopharyngitis  the  use  of  adrenalin  as  a  local  vasomotor  con- 
strictor to  reduce  the  congested  mucous  membrane  and  a  spray  or  instil- 
lation of  camphor,  menthol  and  carbolic  acid  in  some  form  of  hydro- 
carbon oil,  offers  a  soothing  and  antiseptic  application  to  these  tissues. 
In  young  children  a  few  drops  of  this  oily  antiseptic  may  be  injected  with 
a  medicine  dropper  into  the  nose,  the  child's  head  being  held  well  back- 
ward on  the  lap  and  the  fluid  allowed  to  reach  the  pharynx  and  medicate 
these  areas. 

A  case  of '  inflammation  of  the  tympanic  cavity  in  which  a  serous 
exudate  or  undue  congestion  of  the  mucosa  has  not  been  promptly  rec- 
ognized or  given  the  necessary  surgical  drainage  will,  unless  such  exu- 
date is  absorbed  spontaneously,  become  infected  by  one  of  the  various 
pus-producing  microorganisms  responsible  for  the  original  trouble  and 
then  constitutes  an  acute  suppurative  otitis  media. 

Acute  suppurative  otitis  media  may  also  be  developed  per  se  in  the 
course  of  infective  fevers,  influenza,  diphtheria,  tonsillitis,  or  other  acute 
specific  bacteriologic  invasions  of  any  of  the  mucous  areas  directly 
continuous  with  the  Eustachian  tube  and  tympanic  cavity. 

Acute  suppurative  otitis  media  after  perforation  of  the  membrana 
tympani,  runs  a  more  or  less  self-limited  course  of  about  three  or  four 
week's  duration,  unless  some  sequelae  occur.  The  treatment  of  an  acute 
suppurative  otitis  media  is  again  largely  a  matter  of  asepsis  and  proper 
drainage.  If  the  pus  exudating  from  the  tympanic  cavity,  through 
the  perforation  of  the  membrana  tympani,  has  a  free  exit,  and  the  size 
of  such  perforation  is  sufficient  to  admit  of  liberal  draidage  and 
the  position  of  said  perforation  is  sufiiciently  close  to  the  floor  of  the 
tympanic  cavity,  to  ensure  evacuation  of  its  pus  contents  by  such 
drainage,  the  prognosis  is  proportionately  more  favorable  to  thorough 
resolution. 

Considerable  importance  should  be  attached  to  the  bacteriological 
identification  of  the  pus-producing  microorganisms  in  each  case.  If  a 
simple  microscopic  examination  of  the  pus  from  the  ear  is  made  as  a 
routine  practice,  a  fair  notion  of  the  activity  and  possibilities  of  this 
localized  inflammation  may  be  obtained.  When  we  demonstrate  the 
presence  of  streptococcus  pyogenes  in  such  pus,  extensive  invasion  and 
greater  destruction  of  tissue  between  the  tympanic  cavity  and  its  adja- 
cent areas  can  be  expected. 

The  several  forms  of  staphylococci,  if  identified  in  such  pus,  indicate 


SURGERY   OF   THE    EAR  303 

a  less  vicious  form  of  infection  and  one  that  produces  less  destruction 
and  is  more  amenable  to  simple  treatment. 

If,  in  the  course  of  the  usual  treatment  of  an  acute  suppurative 
otitis  media  we  find  a  rise  in  temperature,  diminution  of  discharge  and 
tenderness  over  the  area  of  the  mastoid,  we  are  justified  in  the  con- 
clusion that  an  expansion  of  the  deeper  seated  areas  of  the  tympanic 
cavity  has  taken  place.  If,  in  addition  to  these  symptoms,  we  can  de- 
termine a  sagging  swelling  or  oedematous  change  in  the  appearance  of 
the  posterior,  superior  wall  of  the  external  auditory  canal,  we  have 
further  corroborative  evidence  of  the  invasion  of  the  mastoid  antrum, 
for  it  is  the  expansion  of  such  an  infectious  process  to  the  antrum  that 
produces  the  periostitis  and  infiltration  of  the  deeper  tissues  responsible 
for  such  clinical,  surgical  symptoms.  If  such  a  surgical  symptom- 
complex  is  found,  my  experience  justifies  me  in  the  advice — operate 
without  further  delay! 

An  acute  suppurative  otitis  media  may,  however,  go  on  for  a  period 
of  weeks  and  even  months,  passing  chronologically  into  the  more  chronic 
form,  causing  no  especial  destruction  within  the  tympanic  cavity, 
and  perhaps  eventually,  spontaneously,  gradually  draining  and  drying 
out.     These  cases  are  rather  infrequent. 

Much  more  frequently  the  perforation  in  the  membrana  tympani 
gradually  becomes  large  as  the  drainage  of  pus  continues  through  it, 
granulations  are  produced,  polypi  may  be  formed  protruding  through 
the  perforation  from  the  tympanic  cavity  to  an  extent  where  they  com- 
pletely fill  the  external  auditory  canal,  a  gradual  erosion  of  the  perios- 
teum of  the  ossicles  may  take  place,  or  the  entire  malleus  and  incus 
may  be  slowly  absorbed  in  such  a  long-standing  purulent  process. 

Much  depends  on  the  physical  vitality  of  the  patient  as  to  the  final 
outcome  of  such  a  chronic,  suppurative  process  in  the  tympanic  cavity. 

The  simple  complications  of  chronic  suppurative  otitis  media  and 
their  surgical  attention  may  be  briefly  discussed  as  follows: 

If  the  perforation  in  the  tympanic  membrane  is  large  enough  to 
admit  of  medication  directly  to  the  tympanic  mucous  membrane,  it  is 
my  practice  to  dry  the  tympanic  mucosa  by  cotton-tipped  applicators 
passed  through  the  perforation  into  the  tympanic  cavity,  insufflate 
with  boracic  acid  or  aristol,  or  to  lightly  touch  the  parts  with  a  50  per 
cent,  aqueous  solution  of  argyrol  and  then  pack  in  a  6-in.  strip  of  narrow 
dry,  sterile  gauze,  carrying  the  end  of  the  gauze,  if  possible,  through 
the  perforation  and  packing  the  t>Tnpanic  cavity  and  external  auditory 
canal  by  zigzag  fluting  of  the  gauze. 


304  REGIONAL   SURGERY 

Sterilization,  dryness  and  drainage  are  the-  three  factors  in  the  most 
effective  treatment  of  suppurative  processes  of  any  wound  cavity,  and 
the  tympanic  cavity  is  no  exception  to  this  empirical  rule. 

Granulations  when  present  may  be  treated  with  10  per  cent,  argen- 
tum  nitricum,  50  per  cent,  argyrol,  2  per  cent,  acetate  aluminum,  or  a 
saturated  alcoholic  solution  of  boracic  acid.  The  nitrate  of  silver 
causes  rather  severe  reaction  for  structures  as  delicate  as  those  in  the 
ear  and  is  not  always  desirable;  50  per  cent,  aqueous  solution  of 
argyrol  penetrates  rather  deeper  than  the  silver  but  is  not  quite  as 
astringent  as  the  alcohol;  acetate  of  aluminum  may  be  effective  if  the 
granulations  are  soft  and  small ;  borated  alcohol  is  a  valuable  dehydrant 
and  acts  in  this  capacity  when  instilled  into  the  ear  and  left  in  position 
for  some  10  or  15  minutes,  producing  a  desiccation  of  such  granu-' 
lafion  tissue.  When  these  measures  fail  a  silver  ring-curette  is  the  most 
eft'ective  instrument  for  disposing  of  such  granulation  mass.  The 
tympanic  cavity  may  be  thoroughly  cocainized  through  the  perforation 
in  the  drum-membrane  and  the  curettement  undertaken  under  usual 
aseptic  precautions.  Care  should  be  exercised  that  neither  the  promon- 
tory wall  nor  the  Prussak  spaces  are  injured  when  such  curettement  is 
undertaken.  Following  the  curettement  the  ear  should  be  packed 
rather  firmly  with  gauze,  and  the  packing  renewed  every  12  hours 
for  two  or  three  days. 

A  well-organized  polypus  of  the  ear  is  usually  attached  by  a  some- 
what slender  pedicle  to  some  part  of  the  wall  of  the  tympanic  cavity 
in  which  erosion  has  taken  place.  The  mass  of  the  polypus  most  fre- 
quently forces  its  way  through  the  perforation  of  the  membrana 
tympani  into  the  external  auditory  canal.  Such  polypi  to  be  success- 
fully removed  must  be  engaged  in  the  loop  of  an  aural  snare  and  re- 
moved by  the  pedicle.  If  the  site  of  attachment  of  said  pedicle  can  be 
located  by  inspection  after  the  removal  of  this  mass  it  may  be  touched 
by  a  probe  tipped  with  a  bead  of  pure  chromic  acid  or  of  trichloracetic 
acid. 

Bone  necrosis  occurring  within  the  tympanic  cavity  may  frequently 
be  determined  by  the  pus  washings  from  the  ear.  These,  when 
centrifugalized,  will  demonstrate  the  presence  of  bony  particles  when 
examined  under  the  microscope. 

Necrosis  of  the  ossicles  when  occurring  in  the  course  of  a  suppura- 
tive otitis  media,  should  be  radically  disposed  of  by  ossiculectomy,  the 
removal  of  the  malleus,  or  of  the  malleus  and  incus,  is  not  very  difficult 
if  a  large  perforation  exists,  and  if  the  remnants  of  the  ossicles  are  well 


SURGERY   OF    THE    EAR  305 

exposed.  It  may  frequently  be  accomplished  with  the  small  ring-curette 
used  in  the  disposal  of  granulations.  The  curette  is  passed  well  over 
the  handle  and  neck  of  the  malleus  engaging  the  head  of  the  bone  with 
a  gentle  rocking  upward  leverage.  The  head  of  the  malleus  may  be  de- 
tached from  its  small  suspension  ligament  in  the  attic.  Where  a 
gradual  necrosis  has  existed  in  the  course  of  a  chronic  suppurative  otitis 
media  these  delicate  ligaments  will  have  been  considerably  weakened  and 
the  detachment  and  removal  will  take  place  with  the  expenditure  of  a 
very  httle  force.  The  same  technique  is  carried  out  on  the  incus.  Ex- 
treme care  must  be  used  in  the  removal  of  the  incus  to  avoid  injury  to 
or  dislocation  of  the  stapes.  To  avoid  this  complication  the  articula- 
tion of  the  tip  of  the  incus  with  the  neck  of  the  stapes  must  be  given 
attention  before  the  curette  is  passed  over  the  body  of  the  incus  pre- 
ceding its  removal.  Complete  anaesthesia  of  the  patient  is  distinctly 
desirable  for  such  ossiculectomy  and  the  operation,  slight  as  it  may 
appear,  should  be  done  under  strict  aseptic  precautions,  the  tympanic 
cavity  thoroughly  packed  well  up  into  the  attic  after  the  removal  of  the 
ossicles  and  the  after-treatment  carefully  conducted  to  avoid  an  ex- 
tension of  inflammation  or  pus  processes  beyond  the  attic  areas. 

The  Character  of  the  Discharge. — ^Mucous  secretion  emanates  from 
the  tympanic  cavity  only.  Epithelial  debris,  blood  or  cholestrin  crys- 
tals may  be  found  in  the  more  advanced  cases  of  chronic  suppurative 
otitis  media,  usually  significant  of  cholesteatoma.  Bony  particles 
found  in  the  washings  and  centrifugalization  of  the  discharge  obtained 
in  a  suppurative  process  are  indicative  of  bone  necrosis,  a  thin  watery 
sanguineous  discharge  suggests  granulations,  polypi,  or  occasionally 
even  malignant  neoplasm.  Foul-smelling  pus  of  a  greenish  character 
indicates  bone  necrosis,  profuse  yellow  creamy  pus  of  a  slightly  sweetish 
odor  emanates  from  some  part  of  the  involved  area  where  drainage  is 
inadequate  and  where  the  pus-producing  microorganism  is  more  or  less 
innocuous  in  character. 

The  diagnostic  importance  of  the  location  of  a  perforation  in  the 
membrana  tympani. 

(a)  A  perforation  situated  in  the  antero-inferior  quadrant  is  usually 
indicative  of  chronic  salpingitis. 

(b)  The  perforation  in  Shrapnell's  membrane  indicates  disease  of 
the  attic,  or  of  its  ossicular  contents. 

(c)  A  perforation  in  the  superior-posterior  quadrant  is  usually  asso- 
ciated with  a  necrosis  of  the  ossicles,  more  definitely  of  the  incus  and  of 
the  margin  of  the  aditus,  or  of  the  annulus  tympanicus.     Such  necrosis 


3o6  REGIONAL   SURGERY 

may  even  extend  into  the  antrum.  A  perforation  in  either  the  anterior 
or  posterior-inferior  quadrant,  is  usually  associated  with  a  suppurative 
process  in  the  floor  of  the  tympanic  cavity  the  chronicity  of  which  is 
continued  because  the  drainage  is  insufiicient. 

(d)  In  a  large  kidney-shaped  perforation  with  a  destruction  of 
nearly  all  of  the  membrane  vibrans  is  an  evidence  of  previous  intense 
acute  inflammation  and  erosion  as  we  find  it  so  frequently  in  children 
following  an  invasion  of  the  ear  in  the  eruptive  fevers. 

ACUTE  MASTOIDITIS 

The  mastoid  antrum  communicates  with  the  tympanic  cavity  by  a 
small  opening  called  the  aditus.  This  explains  why  acute  inflammation 
of  the  mastoid  is  practically  always  secondary  to  either  acute  or 
chronic  inflammation  of  the  tympanic  cavity.  The  disease  generally 
starts  in  the  nasopharynx  and  extends  through  the  Eustachian  tube 
to  the  tympanum  and  from  there  through  the  aditus  to  the  antrum  and 
mastoid  cells. 

Cases  have,  however,  been  described  and  unquestionably  do  occur 
in  which  the  mastoid  cells  are  primarily  involved,  there  being  no  con- 
comitant signs  of  middle-ear  inflammation.  Such  cases  are  usually 
influenzal  in  origin  and  although  the  route  of  infection  may  be  hemat- 
ogenous it  is  more  likely  to  be  auditory,  notwithstanding  that  the  or- 
ganisms, in  their  passage  through  the  tympanic  cavity,  have  not  lodged 
there  and  given  rise  to  inflammation. 

Acute  mastoiditis  may  follow  prolonged  exposure  to  wet  or  cold 
with  consequent  lowering  of  the  natural  resistance  of  the  part  and 
greater  susceptibility  to  pyogenic  infection.  It  may  follow  measles, 
scarlet  fever,  diphtheria,  tonsillitis,  typhoid  fever,  syphilis  and 
tuberculosis. 

The  organisms  that  have  been  isolated  from  mastoid  infections 
include  the  various  streptococci,  the  staphylococci,  pneumococcus, 
bacillus  of  Friedlander,  bacillus  of  influenza,  tubercle  bacillus,  the 
streptococcus  mucosus  capsulatus,  etc.  The  last-mentioned  organism 
is  of  special  interest  in  a  consideration  of  mastoid  disease  because  it  has 
a  tendency  to  produce  few  cHnical  symptoms  and  a  stringy,  persistent 
discharge. 

In  a  case  of  acute  otitis  media  followed  by  acute  mastoiditis  it  may 
happen  that  both  mastoids  may  be  involved  simultaneously. 

The  presence  of  infectious  material  within  the  mastoid  leads  to 


SURGERY   OF   THE   EAR  307 

local  necrosis  with  the  formation  of  a  sequestrum  which  is  either 
discharged  spontaneously  or  must  be  removed  by  operation.  Usually 
the  pus  escapes  by  the  most  direct  route  and  this  is  through  the  aditus 
into  the  tympanic  cavity,  and  if  there  is  a  perforation  in  the  drum, 
into  the  auditory  canal.  But  if  drainage  is  insufficient  it  will  travel 
along  the  path  of  least  resistance  causing  caries  of  the  bone  and,  as  the 
inflammatory  process  extends  to  the  surface  of  the  bone,  periostitis. 

The  pus  may  become  evacuated  either  (i)  through  the  external 
mastoid  cortex,  behind  the  ear  or  the  external  meatus;  (2)  through  the 
cortex  into  the  digastric  fossa  with  the  formation  of  an  abscess  beneath 
the  fascia  of  the  sternocleido-mastoid  muscle,  forming  what  is  known 
as  BezoWs  mastoiditis;  (3)  through  the  roof  of  the  antrum  or  the 
tympanic  vault  into  the  middle  cranial  fossa;  or  (4)  into  the  lateral 
sinus  and  the  posterior  cranial  fossa. 

The  symptoms  of  acute  mastoiditis  will  be  influenced  in  their 
intensity  by  three  factors:  {a)  the  virulence  of  the  infection;  {h)  the  re- 
sistance to  the  escape  of  pus  and  (c)  the  stage  of  the  infection. 

There  is  usually  a  history  of  either  acute  or  chronic  middle-ear 
inflammation  or  attacks  of  earache  with  or  without  discharge.  Even 
in  an  acute  case  otorrhea  may  be  absent  and  in  the  subacute  and  chronic 
cases  of  middle-ear  inflammation  local  examination  may  show  no  per- 
foration and  little  evidence  of  trouble. 

The  two  cardinal  symptoms  indicative  of  acute  mastoiditis  are: 
(i)  mastoid  tenderness  and  (2)  bulging  of  the  postero-superior  portion  of 
the  auditory  canal.  Periosteal  inflammation  or  the  formation  of  a 
subperiosteal  abscess  will  produce  a  characteristic  forward  and  down- 
ward displacement  of  the  auricle.  The  mastoid  process  will  also  feel 
boggy  to  touch  and  if  the  collection  of  pus  be  more  considerable  there 
may  be  fluctuation. 

Fever  is  practically  always  associated  with  the  pain.  Where  there 
is  free  escape  of  pus  absence  of  fever  is  not,  however,  uncommon. 
The  fever  and  the  pain  seem  to  be  dependent  upon  the  amount  of  pus 
retention.  A  low  temperature  is  not  an  indication  that  the  case  is  of 
but  slight  seriousness. 

Persistent  otorrhea  is  always  regarded  as  a  prominent  symptom 
pointing  to  mastoid  suppuration,  especially  when  associated  with  mas- 
toid pain.  But  not  all  cases  of  acute  mastoiditis  show  any  discharge. 
The  discharge  may  be  absent  because  there  is  no  perforation  of  the 
drum;  or  the  discharge  may  have  ceased  because  of  obstruction  to  the 
outflow  of  pus  from  the  aditus,  in  which  event  examination  of  the 


3o8  REGIONAL   SURGERY 

ear  will  show  some  evidence  of  recent  suppuration ;  or  there  may  be  a 
history  of  previous  discharge  from  the  middle  ear  which  had  become 
blocked  by  granulations  and  polypi. 

Pain  is  a  constant  symptom  and,  as  already  mentioned,  is  de- 
pendent in  its  intensity  upon  the  amount  of  pus  retention.  In  adults 
with  sclerosis  of  the  mastoid  process,  because  of  the  greater  difficulty 
to  the  exit  of  pus,  the  pain,  fever  and  constitutional  reaction  may 
be  extremely  severe. 

In  determining  whether  or  not  the  mastoid  is  diseased  the  X-ray 
has  proven  of  great  service,  especially  in  those  cases  where  there  are 
few  or  indefinite  symptoms.  The  results  of  X-ray  examination  have 
been  so  encouraging  that  for  completeness  of  diagnosis  rontgenization 
may  be  recommended  as  a  routine  measure  in  conjunction  with  the  clin- 
ical examination. 

In  simple  cases  the  prognosis  is  favorable.  The  longer  the  duration 
of  the  mastoid  infection  and  the  more  advanced  the  local  necrosis 
the  greater  is  the  danger  of  intracranial  complications. 

Treatment. — If  seen  in  the  first  stage  before  pus  has  formed  the 
patient  should  be  given  a  calomel  purge,  followed  by  a  saline  cathartic, 
and  immediately  put  to  bed.  If  there  is  fluid  within  the  tympanum 
the  drum  should  be  freely  incised  along  its  posterior  border  to  facilitate 
drainage.  The  mastoid  region  should  be  painted  with  Churchill's 
tincture  of  iodine.  Sometimes  these  expectant  measures  may  produce 
improvement  but  if  no  amelioration  of  the  condition  is  noticeable 
within  24  to  36  hours  or  if  there  is  an  aggravation  in  the  condition 
operation  should  be  resorted  to  without  delay. 

CHRONIC  MASTOIDITIS 

The  pathological  condition  in  chronic  mastoiditis  depends  largely 
upon  the  variety  of  cellular  structure  of  the  bone.  It  may  be  composed 
of  one  of  three  chief  types  of  cells:  the  pneumatic,  in  which  the  cells 
are  few  and  large;  the  diploic,  in  which  the  cells  are  small  and  numerous; 
and  the  compact,  in  which  the  bone  is  extremely  dense.  If  the  structure 
be  of  the  pneumatic  or  diploic  types,  caries  may  cause  gradual  absorp- 
tion of  the  bone,  the  cavity  thus  formed  becoming  filled  with  granula- 
tions, epithelial  debris  and  inspissated  pus  and  communicating  by 
means  of  fistulie  with  the  auditory  canal  anteriorly,  or  with  the  skin 
over  the  mastoid  process  externally  or  with  the  labyrinth,  particularly 
with  the  inferior  semicircular  canal,  internally. 


SURGERY    OF    THE   EAR  309 

Where  the  bone  is  of  the  compact  variety  a  gradual  process  of 
osteosclerosis  may  ultimately  make  it  of  extreme  hardness. 

Except  where  there  is  an  acute  exacerbation  of  the  disease  with 
the  clinical  picture  of  an  acute  mastoiditis  or  an  intracranial  com- 
plication, the  symptoms  of  chronic  mastoiditis  may  be  very  vague.  So 
long  as  drainage  is  unobstructed  the  temperature  may  remain  normal. 
The  discharge  may  be  the  only  symptom.  Headache,  neuralgic  pains, 
vertigo  and  tinnitus  when  present  are  to  be  attributed  to  some  inter- 
ference with  the  escape  of  the  discharge.  Pyrexia  must  be  regarded 
as  a  danger  signal  for  if  it  recurs  or  persists  it  is  an  indication  that 
there  is  some  pus  retention  within  the  mastoid  or  that  there  is  an  in- 
tracranial complication. 

Examination  of  the  ear  will  always  show  signs  of  chronic  inflamma- 
tion but  such  signs  do  not  often  tell  to  what  extent  the  mastoid  process 
is  affected  for  the  mastoid  when  opened  may  show  greater  destructive 
changes  than  were  anticipated. 

The  diagnosis  depends  upon  the  history  and  signs  of  middle-ear 
disease  with  occasional  symptoms  of  pus  retention.  The  X-ray  may 
be  of  great  aid  in  clearing  up  the  diagnosis  and  in  differentiating  the 
condition  from  furunculosis. 

THE  MASTOID  OPERATION 

Indications  for  the  Simple  Mastoid,  or  Schwartze,  Operation. — 

1.  When  there  is  an  abscess  over  the  mastoid  process. 

2.  When  there  is  persistent  fever  and  pain  in  acute  otitis  notwith- 
standing that  drainage  is  free. 

3.  When  there  is  profuse  purulent  discharge  with  downward 
bulging  of  the  supero-posterior  wall  of  the  auditory  canal. 

4.  When  there  is  empyema  of  the  antrum  and  free  drainage  must 
be  established. 

5.  When  there  are  symptoms  of  meningeal  irritation,  even  though 
drainage  is  free,  especially  if  the  condition  is  influenzal  in  origin. 

Surgical  Topography. — Where  the  upper  posterior  wall  of  the 
bony  meatus  terminates  or  merges  into  the  outer  surface  of  the  mastoid 
there  is  a  crescentic  bony  spine  known  as  the  suprameatal  or  Henle^s 
spine.  The  center  of  this  spine  marks  fairly  accurately  the  position  of 
the  floor  of  the  aditus.  From  the  anterior  portion  of  the  zygoma  and 
running  backward  and  more  or  less  upward  upon  the  squamous  portion 
of  the  temporal  bone  is  a  well-defined  ridge  forming  part  of  the  temporal 


3IO 


REGIONAL   SURGERY 


ridge.  That  portion  of  it  which  is  above  the  bony  meatus  and  Henle's 
spine  is  the  posterior  root  of  the  zygoma  which  represents  the  level  of 
safety  in  entering  the  middle  fossa  of  the  skull. 

The  suprameatal  or  Macewen's  triangle  is  a  triangular  space  between 
the  lower  posterior  edge  of  the  root  of  the  zygoma  and  the  superior 
posterior  edge  of  the  opening  of  the  external  auditory  meatus  (Fig.  159). 

If  we  imagine  a  more  or  less  horizontal  line  passing  through  the 
center  of  Henle's  spine,  its  anterior  extension  forming  an  angle  of 
about  15  degrees  with  the  upper  margin  of  the  zygoma  it  will  indicate 
with  fair  accuracy  the  horizontal  portion  of  the  facial  canal  on  the 
inner  wall  of  the  tympanic  cavity.     If  we  imagine  a  vertical  line 


Fig.  159. — Surgical  landmarks  of  mastoid  cortex,  a,  Henle's  spine;  b,  posterior  root 
of  zygoma;  g,  temporal  ridge;  c-d,  direction  of  horizontal  portion  of  facial  canal;  e-f,  direc- 
tion of  descending  portion  of  facial  canal.     {After  Kerrison.) 


passing  through  the  center  of  Henle's  spine  it  will  be  a  fairly  accurate 
guide  to  the  descending  portion  of  the  facial  canal,  from  its  genu 
beneath  the  floor  of  the  aditus  to  its  termination  in  the  stylo-mastoid 
foramen. 

Description  of  the  Operation. — The  patient  is  prepared  as  for  any 
other  major  operation.  The  head  is  shaved  for  2  or  3  in.  around  the 
mastoid  region  and  the  operative  field  is  thoroughly  washed  with  soap 
and  water,  painted  with  tincture  of  iodine  followed  by  alcohol. 

Instruments  Required. — Rongeur  forceps  of  various  sizes,  re- 
tractors (Jansen's  self-retaining),  a  mallet,  a  scalpel,  chisels  of  vari- 
ous sizes,  hemostats,  periosteal  elevators,  gouges,  sharp  spoons,  burrs, 


SURGERY   OF   THE    EAR 


311 


clips  or  needles  and  needle  holder,  silk  and  catgut  sutures,  a  seeker  or 
probe. 

Technique  of  the  Operation.- — While  the  auricle  is  gently  held  for- 
ward an  incision,  3^  in.  behind  the  auricle,  running  in  a  curved  line 
parallel  with  its  line  of  insertion  is  made  from  the  upper  point  of  insertion 
of  the  pinna  down  to  the  mastoid  tip.  The  position  of  the  incision 
will  depend  upon  the  amount  of  infiltration  and  how  much  bond  de- 
struction is  suspected  (Fig.  160).  It  may  be  made  further  backward,  if 
necessary,  or  its  curvature  may  be  increased.  For  additional  space  an 
incision  at  right  angles  to  the  first  may  be  made. 


Fig.  160.  Fig.  161. 

Fig.  160. — Showing  initial  incision  for  mastoid  operation,  a-b,  c-d,  incisions;  e,  shaved 
area. 

Fig.  161. — Macewen's  triangle,  i,  Henle's  spine;  2,  posterior  root  of  zygoma;  3,  posi- 
tion of  antrum;  4,  position  of  lateral  sinus;  5,  area  of  bone  removed  in  simple  mastoid 
operation;  6,  tip  of  mastoid  process;  7,  fibrous  positions  of  post,  wall  of  ext.  auditory  canal. 
(Adapted  from  Tod.) 

The  soft  tissues  are  separated  in  front  of  and  behind  the  incision 
by  means  of  a  periosteal  elevator  exposing  a  triangular  area  of  bone 
(suprameatal  or  Macewen's  triangle)  bounded  in  front  by  the  posterior 
upper  margin  of  the  bony  meatus  and  Henle's  spine,  above  by  the 
posterior  root  of  the  zygoma  and  below  by  fibers  of  the  sternocleido- 
mastoid muscle  (Fig.  161). 

The  edges  of  the  wound  are  kept  apart  with  retractors  by  an 
assistant  or,  better,  by  a  self-retaining  Jansen  retractor  inserted  at 
each  extremity  of  the  wound.  All  bleeding  points  should  be  immedi- 
ately arrested  by  hemostats  and  then  tied  if  ligation  seems  necessary. 

When  the  surface  of  the  bone  has  been  exposed  by  the  separation 
of  its  periosteum  any  softened  portion  of  the  mastoid  cortex  should  be 
removed  by  means  of  a  curette  or  a  rongeur  forceps. 


312 


REGIONAL   SURGERY 


To  reach  the  antrum  the  bone  is  chiselled  away  by  means  of  a 
gouge  held  in  contact  with  the  bone  in  a  sloping  direction  and  tapping 
the  instrument  with  a  mallet.  This  procedure  is  carried  out  in  a  down- 
ward and  forward  direction. 

Granulations  and  carious  bone  that  may  be  present  are  curetted 
away. 

The  operative  field  should  be  constantly  kept  clean  and  dry  by 
sponges  of  sterilized  gauze. 

When  the  antrum  is  opened  any  pus  that  exudes  must  be  wiped 
away  at  once.  Granulations,  carious  bone  and  cells  communicating 
with  the  antrum  should  be  removed  by  curette.  This  part  of  the  opera- 
tion must  be  fairly  radical  removing,  if  necessary,  all  the  cells  down  to 
the  tip  of  the  mastoid  process  and  exposing  the  dura  mater  and  the  lat- 
eral sinus. 

It  is  not  enough  to  thoroughly  cleanse  the  main  abscess  cavity. 
There  are  a  few  cellular  spaces  above  the  meatus  in  the  root  of  the 
zygoma  any  of  which,  if  left,  may  lead  to  the  formation  of  a  discharging 
sinus  or  fistula.  Hence  it  is  advisable,  to  obviate  this  possibility,  to 
make  the  bone  cavity  larger  by  chiseling  away  the  overhanging  edge  of 
bone  above  and  behind  the  meatus  at  the  root  of  the  zygoma.  Also, 
near  the  tip  of  most  mastoid  processes,  even  of  the  diploic  type,  a  large 
cell  is  present  which  it  is  best  to  expose  and  if  found  to  be  filled  with 
granulations  or  infectious  material  these  should  be  curetted  away  until 
the  cell  is  thoroughly  cleaned  and  normal  bone  laid  bare. 

Where  this  cell  has  undergone  abscess  formation  perhaps  with 
perforation  through  the  median  wall  and  gravitation  of  pus  into  the 
deeper  tissues  of  the  neck  (Bezold  mastoiditis)  it  will  be  necessary 
to  remove  the  entire  tip  of  the  mastoid.  For  this  purpose  the  incision 
through  the  skin  should  be  lengthened  along  the  anterior  border  of  the 
sterno-mastoid  muscle,  the  muscular  attachment  at  the  tip  severed 
and  the  tip  removed  with  a  rongeur  forceps  or  with  a  bone  gouge. 

The  mastoid  cavity  having  been  curetted  until  healthy  bone  is 
reached  the  rough  edges  are  smoothed  down  by  means  of  a  chisel  or  burr. 

The  wound  is  then  flushed  out  with  sterile  water  or  with  1:5000 
bichlorid  solution  and  if  the  tympanic  membrane  contain  a  perforation 
the  aditus  and  tympanic  cavity  are  also  syringed  so  that  the  fluid  flows 
out  of  the  external  meatus.  A  strip  of  gauze  should  be  inserted  into 
the  ear  for  drainage. 

The  mastoid  cavity  is  now  packed  with  iodoform  gauze  and  the 
edges  of  the  wound  sutured  or  held  in  apposition  by  means  of  Michel's 


SURGERY   OF   THE   EAR 


6^6 


metal  clips,  a  free  opening  being  left  for  the  drain.  The  wound  is  then 
dressed. 

After-treatment. — As  a  rule,  the  lirst  dressing  may  be  allowed  to 
remain  for  three  or  four  days.  During  the  first  day  or  two  after  the 
operation  it  is  not  uncommon  to  have  a  somewhat  intermittent 
temperature.  This  should  occasion  no  alarm  unless  it  is  associated 
with  vomiting,  inequality  or  sluggish  reaction  of  the  pupils  or  other 
cranial  symptoms. 

The  succeeding  dressings  may  be  changed  every  other  day.  The 
drain  is  removed  and  the  cavity  syringed  out  with  sterile  water  or 
boric  acid  solution  and  a  new  drain  of  sterile  gauze  inserted.  The 
syringing  may  be  omitted  if  there  is  no  pus  or  abundant  secretion. 
The  most  scrupulous  care  should  be  taken  in  regard  to  cleanliness  and 
asepsis.  The  silk  sutures  or  the  metal  clips  should  be  removed  by  the 
third  day  to  prevent  sloughing. 

Indications  for  the  Radical  Mastoid  Operation. — 

1.  Acute  mastoiditis  associated  with  chronic  suppurative  otitis 
media. 

2.  Cholesteatoma,  from  which  septic  thrombosis  is  likely  to  occur. 

3.  Intracranial  suppurative  lesions. 

4.  Tuberculosis  of  the  middle  ear. 

5.  Fistulae  of  the  mastoid  process. 

6.  Pus  retention  within  the  antrum  and  mastoid  associated  with 
repeated  attacks  of  vertigo,  nausea  and  headache.  Retention,  also, 
from  recurring  polypi  and  granulations. 

7.  Purulent  labyrinthitis. 

8.  Facial  paralysis  occurring  in  the  course  of  chronic  suppurative 
otitis  media,  which  signifies  that  the  inflammation  has  attacked  the 
Fallopian  canal  and  is  extending  to  the  internal  ear. 

Description  of  the  Operation. — The  patient  having  been  properly 
prepared  for  operation  a  curved  incision,  with  another  at  right  angles 
to  it  for  additional  space,  is  made  behind  the  auricle,  as  in  the  simple 
mastoid  operation.  The  soft  parts  and  the  periosteum  are  then  pushed 
aside  with  an  elevator  until  the  suprameatal  triangle  is  exposed;  the 
operative  field  is  kept  open  by  means  of  retractors,  as  in  the  simple 
mastoid  operation. 

As  in  the  simple  operation  the  antrum  is  entered  and  the  cavity  en- 
larged by  curette.  Inspissated  pus,  necrotic  bone  and  granulations  are 
thoroughly  removed  with  a  sharp  curette. 

The  posterior  wall  of  the  membranous  portion  of  the  auditory 


314  REGIONAL   SURGERY 

canal  is  separated  from  the  posterior  wall  of  the  bony  portion  and 
drawn  forward  by  means  of  a  retractor,  together  with  the  auricle, 
and  held  out  of  the  operator's  way  by  an  assistant  (Fig.  162).  The 
wall  between  the  auditory  opening  and  the  opening  into  the  antrum  is 
now  removed  in  wedge-shaped  fashion  by  chiseling  from  above  down- 
ward and  from  below  upward.  This  bridge  of  bone  must  be  removed 
in  order  to  get  to  the  attic  and  tympanic  cavity,  because  the  object  of 
the  operation  is  to  convert  the  interior  of  the  mastoid,  the  tympanic 
cavity  and  the  auditory  canal  into  one  chamber. 

This  step  is  one  of  the  most  difficult  in  the  whole  operation  because 
the  facial  nerve,  lying  in  the  Fallopian  canal,  runs  directly  under 
this  bridge  of  bone  and  the  lumen  of  the  aditus  lies  between  the  nerve 
and  the  bridge.     In  the  floor  of  the  aditus,  also,  Hes  the  horizontal 


Fig.  162. — I,  Semicircular  canal;  2,  attic;  3,  antrum;  4,  mastoid;  5,  inner  wall  of  tympanic 
cavity.     {Adapted  from  Tod.) 

semicircular  canal.  To  prevent  accidental  injury  to  these  structures 
a  Stacke  protector  should  be  used;  but  if  too  much  pressure  be  placed 
on  the  instrument  in  the  course  of  removing  the  bone  the  facial  nerve 
may  be  injured  by  crushing. 

Instead  of  using  the  chisel  and  Stacke  protector  in  the  removal 
of  the  bridge  of  bone  the  Kerrison  forceps  may  be  employed.  This  is 
used  in  the  following  way:  The  beak  of  the  instrument,  which  serves 
as  a  protector,  is  very  gently  inserted  through  the  aditus.  By  compres- 
sing the  handles  the  cutting  surfaces  in  the  upper  jaw  of  the  instrument 
are  forced  through  the  bone  which  is  thus  bitten  away. 

The  outer  wall  of  the  aditus  having  been  removed  the  attic  is  ex- 
plored and  curetted  so  that  all  diseased  bone  and  granulations  are 
removed.     As  the  facial  nerve  crosses  the  inner  wall  of  the  attic  it  is 


SURGERY    OF   THE   EAR  315 

safer,  to  avoid  injuring  it,  to  keep  to  the  outer  wall.  The  curettement 
should  be  continued  until  a  clear  view  of  the  tegmen  is  obtained  and 
there  are  no  overhanging  ridges  of  bone. 

The  attic  is  now  lightly  packed  for  a  few  minutes  or  thoroughly 
sponged  in  order  to  remove  all  blood  and  chips  of  bone. 

The  tympanic  cavity  having  been  exposed  and  opened,  the  stape- 
dius muscle  and  the  incudo-stapedial  articulation  are  severed  and 
the  malleus  and  incus  removed. 

In  order  to  prevent  subsequent  re-infection  from  the  nasopharynx 
the  mouth  of  the  Eustachian  tube  may  also  be  curetted  so  as  to  pro- 
duce a  scar  and  obtain  obliteration  of  the  mouth  of  the  tube.  But 
in  doing  this  the  position  of  the  carotid  canal,  downward  and  back- 
ward, should  be  uppermost  in  the  surgeon's  mind  because  the  employ- 
ment of  sharp  instruments  in  that  direction  necessitates  extreme 
caution  and  a  very  clear  conception  of  anatomical  relations. 

The  middle-ear  cavity  is  sponged  and  inspected  and  thoroughly 
curetted. 

The  entire  cavity  is  smoothed  down  by  a  chisel  or  burr  so  that 
there  are  no  points  of  projection  except  the  slight  ridge,  the  remains  of 
the  posterior  wall  of  the  bony  meatus,  at  the  innermost  extremity  of 
which  the  horizontal  semicircular  canal  is  situated. 

The  bony  cavity  is  flushed  out  with  sterile  water,  boric  acid  solution 
or  1 :  5000  bichlorid  solution. 

It  is  then  packed  with  sterile  gauze. 

Posterior  meatal  skin  flaps  are  now  made.  The  flap  most  generally 
employed  is  that  of  Panse  in  which  the  skin  of  the  meatus  is  slit  along 
its  posterior  surface  to  the  concha  where  two  right-angled  incisions 
are"*made  one  upward  and  the  other  downward.  These  are  stitched 
to  the  periosteum  and  subcutaneous  tissue  with  catgut.  Other  flaps 
that  have  been  recommended  are  the  modified  Panse  or  Y-shaped  flap  of 
Passow;  the  Korner  flap  made  by  two  incisions,  one  along  the  postero- 
superior,  the  other  along  the  postero-inferior  border  of  the  auditory 
meatus,  starting  at  its  median  aspect  out  to  the  concha;  the  Ballance 
flaps  made  by  an  incision  from  the  median  aspect  of  the  meatus  to  the 
concha  and  around  the  concha  in  the  form  of  a  hook. 

The  purpose  of  the  flaps  is  to  hasten  epithelialization  of  the  raw 
surface  of  the  wound.  The  uncovered  space  between  the  flaps  may  be 
allowed  to  heal  by  granulations  or  may  be  grafted  at  the  time  of  the 
operation  or  lo  days  later  by  the  improved  Thiersch  graft  as  described 
by  Dench. 


3l6  REGIONAL   SURGERY 

The  operation  is  terminated  by  packing  the  wound  with  sterile 
plain  or  iodoform  gauze  and  approximating  the  edges  either  with  silk 
sutures  or  with  Michel's  clips,  as  in  the  simple  mastoid  operation. 

A  dry  dressing  is  then  applied  over  the  whole  side  of  the  head  and 
allowed  to  remain  for  four  or  five  days  unless  pain,  fever  or  other  symp- 
toms necessitate  its  earlier  removal  for  inspection  of  the  wound. 

After-treatment  does  not  differ  from  that  of  the  simple  mastoid 
operation.  After  the  first  dressing  the  wound  should  be  dressed  every 
other  day  unless  there  be  purulent  discharge  when  the  dressing  may 
have  to  be  changed  daily.  The  ear  or  wound  may  be  syringed  with 
boric  acid  or  with  i  :5ooo  bichlorid  solution,  if  the  discharge  requires  it, 
before  being  re-packed. 

Granulations  should  be  removed  by  curette  and  if  they  recur  it 
may  indicate  that  there  is  still  a  small  patch  of  carious  bone  that  re- 
quires removal. 

The  Conservative  Radical  or  Heath  Operation. — This  operation, 
devised  by  Heath,  is  based  on  the  theory  that  in  most  instances  the 
Eustachian  tube,  instead  of  being  a  constant  danger  of  re-infection, 
is  able  to  drain  the  discharges  from  the  attic  and  tympanum.  The 
middle  ear  is,  therefore,  not  exenterated.  Throughout  the  operation 
all  exploration  of  the  tympanic  cavity  with  a  probe  or  other  instrument 
is  avoided  and  the  drum-membrane  and  ossicles  are  preserved  intact. 
When  removing  the  posterior  wall  of  the  bony  meatus  down  to  the 
annulus  tympanicus  the  bridge  of  bone  overlying  the  aditus  must  be 
left  intact,  otherwise  the  tympanic  membrane  and  the  ossicles  would 
be  destroyed. 

At  the  time  of  the  mastoid  operation  the  attic  is  thoroughly 
cleansed  through  the  aditus  by  means  of  a  syringe.  With  a  Politzer 
bag  air  is  blown  into  the  middle  ear  and  through  the  perforation  in  the 
drum  so  that  retained  pus,  polypi  and  granulations  are  driven  into  the 
external  auditory  meatus  from  which  they  are  easily  removed. 

The  after-treatment  consists  in  inserting  a  curved  cannula  through 
the  middle  ear  and  perforated  drum-membrane.  Otherwise  the  treat- 
ment is  the  same  as  after  the  other  mastoid  operations. 

Suitable  for  the  Heath  operation  are  those  cases  of  chronic  mastoidi- 
tis in  which  the  hearing  and  the  ossicles  are  only  moderately  affected 
and  in  which  the  tympanic  membrane  is  not  only  perforated  but  largely 
destroyed. 


SURGERY   OF   THE   EAR  317 

INTRACRANIAL   COMPLICATIONS  OF   CHRONIC   MIDDLE- 
EAR  AND   MASTOID   DISEASE 

Intracranial  complications  due  to  direct  extension  of  the  pyogenic 
infection  from  the  middle  ear  will  in  a  great  measure  depend  upon  the 
direction  taken  by  the  bone  disease  toward  the  cranial  cavity.  If 
the  path  of  infection  be  upward  through  the  petro-squamous  fissure 
or  along  the  petro-squamous  sinus  there  will  result  either  a  temporo- 
sphenoidal  abscess,  an  extradural  abscess  or  meningitis  of  the  middle 
fossa.  If  the  path  of  infection  be  downward,  through  the  floor  of  the 
ear,  thrombosis  of  the  jugular  bulb  will  result.  If  backward,  involving 
the  mastoid  cells,  there  may  follow  either  an  extradural  abscess,  lateral 
sinus  thrombosis  or  cerebellar  abscess.  If,  finally,  the  path  of  infection 
be  inward  to  the  petrous  portion  of  the  temporal  bone  there  may  result 
either  suppuration  in  the  labyrinth,  meningitis  or  cerebellar  abscess. 

Extradural  abscess  is  the  most  frequent  complication;  next  in 
frequency  comes  lateral  sinus  thrombosis  and  finally  intracranial 
disease. 

Extradural  Abscess.— Extradural  abscess  is  more  often  the  result 
of  acute,  rather  than  of  chronic,  suppurative  conditions  of  the  middle 
ear  and  mastoid.     The  most  frequent  etiological  factor  is  influenza. 

There  is  severe  and  persistent  headache  localized  to  the  affected 
side,  and  moderate  fluctuating  fever.  Localizing  symptoms  will  de- 
pend largely  upon  the  size  attained  by  the  abscess.  When  these  are 
present  there  are  signs  of  cerebral  irritation  and  compression  (twitch- 
ings  and  paralysis  of  the  extremities  of  the  opposite  side,  vertigo,  vomit- 
ing, retraction  of  the  neck).  Aural  discharge,  aural  and  mastoid  pain 
may  be  absent  in  atypical  cases. 

Sinus  Thrombosis. — ^Lateral  sinus  thrombosis  may  follow  middle- 
ear  suppuration  without  any  mastoid  involvement  chiefly  through 
the  communication  of  the  lateral  sinus  with  the  superior  petrosal  sinus. 
It  is  ordinarily  liable  to  thrombosis  from  mastoiditis  because  of  the  free 
communication  that  exists  between  it  and  the  mastoid  by  means  of 
the  mastoid  veins.  The  sigmoid  portion  of  the  sinus  is  the  part  most 
frequently  attacked.  The  jugular  bulb  may  become  infected  through 
the  floor  of  the  middle  ear. 

The  thrombus  is  generally  at  first  obstructive  and  not  infective. 
Bacterial  invasion  only  occurs  later  and  then  the  thrombus  undergoes 
softening  and  disintegration.  Clinically,  this  distinction  is  of  no  im- 
portance because  the  preinfected  period  of  the  thrombus  is  not,  as  a 


3l8  REGIONAL   SURGERY 

rule,  recognized.  Symptoms  appear  when  sepsis  appears.  There  is  a 
sudden  rise  in  temperature  followed  by  a  fall  to  normal  or  nearly 
normal  and  accompanied  by  rigor  or  profuse  perspiration.  This  is 
then  repeated  so  that  we  have  a  typical  intermittent  or  remittent 
temperature. 

Cases  occur,  however,  where  the  infective  thrombus  becomes 
surrounded  by  healthy  clot  so  that  no  septic  material  passes  into 
the  general  circulation  and  there  are  no  constitutional  symptoms. 
There  are  local  symptoms  of  headache,  vomiting  and  vertigo. 

Choked  disc  is  present  in  about  50  per  cent,  of  cases.  A  fundus 
examination  should  always  be  made  for  the  presence  of  optic  neuritis. 

A  complication  of  acute  mastoiditis  which  is  likely  to  obscure  the 
existence  of  sinus  thrombosis  and  thus  lead  to  a  fatality  is  pyelitis. 
Pyelitis  may  sometimes  simulate  sinus  thrombosis.  It  may  also  be 
present  in  addition  to  the  sinus  thrombosis,  as  in  a  case  recently  seen 
by  the  writer,  where  it  may  be  held  responsible  for  the  clinical  condi- 
tion and  the  characteristic  temperature  curve  until  these  become  too 
violent  to  be  thus  explained.  By  that  time,  however,  operation  for 
the  sinus  thrombosis  will  have  been  delayed  too  long.  Hence,  where 
the  clinical  symptoms,  even  in  the  presence  of  a  pyelitis,  are  sugges- 
tive of  sinus  thrombosis  it  is  perfectly  justifiable  to  do  an  explora- 
tory sinus  operation  to  determine  the  presence  or  absence  of  sinus 
involvement. 

Sinus  thrombosis  requires  either  a  simple  or  a  radical  mastoid  opera- 
tion with  free  exposure  of  the  lateral  sinus  and  complete  removal  of  the 
infected  clot. 

Brain  Abscess.— Chronic  middle-ear  suppuration  is  the  usual  cause 
of  this  complication.  The  abscess  is  located  in  the  temporo-sphenoidal 
lobe  or  in  the  cerebellum.  The  former  is  about  twice  as  frequent  as  the 
latter  and  follows  attic  suppuration;  the  latter  follows  suppuration  of 
the  posterior  mastoid  cells. 

The  symptoms  characteristic  of  brain  abscess  are  those  of  (a) 
intracranial  pressure:  headache,  vomiting,  optic  neuritis,  slow  pulse 
and  subnormal  temperature;  and  {h)  localizing  symptoms.  Pointing 
to  temporo-sphenoidal  abscess  are  slow  pulse,  drowsiness  or  coma, 
paralysis  of  the  opposite  side,  subnormal  temperature,  deafness  of  the 
opposite  side,  aphasia,  if  the  abscess  is  on  the  left  side.  Pointing  to 
cerebellar  abscess  are  vertigo,  nystagmus,  staggering  gait,  absence  of 
patellar  reflex,  facial  paralysis  (of  the  same  side). 

In    temporo-sphenoidal    abscess    the    radical    mastoid    operation, 


SURGERY   OF   THE   EAR  319 

as  already  described,  should  be  performed  and  the  post-auricular  in- 
cision extended  upward  and  forward  around  the  upper  border  of  the 
auricle  and  the  flap  turned  back.  The  bone  above  the  external  audi- 
tory meatus  is  removed  with  the  chisel  and  bone  forceps  and  the 
opening  enlarged  so  that  the  dura  is  fully  exposed.  If  the  bone  is  very 
dense  the  opening  may  be  made  with  a  trephine.  This  opening  should 
be  at  least  ^  in.  in  diameter.  If  the  dura,  when  exposed,  is  found  to 
be  of  normal  color  and  pulsating,  the  button  of  bone  may  be  replaced. 
If,  however,  the  dura  bulges  and  does  not  show  pulsation,  an  incision 
is  made  through  the  membrane  and  the  brain  explored  for  the  abscess. 
For  this  purpose  it  is  more  advisable  to  use  a  sharp-pointed,  long, 
narrow  knife.  A  hollow  trocar  or  needle  may  become  stopped  up  with 
brain  tissue  and  pass  through  the  abscess  without  giving  evidence  of 
pus. 

If  the  abscess  is  found  the  wound  may  be  slightly  enlarged  to  allow 
free  escape  of  the  pus  and  the  abscess  cavity  is  washed  out  with  sterile 
normal  salt  solution  to  clear  away  inspissated  or  cheesy  material  too 
thick  in  consistency  to  flow  out  with  the  rest  of  the  pus.  By  means 
of  the  Whiting  encephaloscope  the  abscess  cavity  may  be  inspected, 
irrigated  and  a  drain  inserted  without  bruising  the  normal  brain  tissue. 

In  exploration  of  the  temporo-sphenoidal  lobe  it  should  be  remem- 
bered that  an  explorer  or  knife  cannot  be  inserted  for  more  than  4 
cm.  or  1^5  in.,  without  endangering  the  lateral  ventricles. 

After  the  abscess  cavity  has  been  thoroughly  cleaned  out  a  strip 
of  iodoform  gauze,  3^^  in.  wide,  with  a  selvage  edge,  is  inserted  by 
means  of  a  slender  dressing  forceps  through  the  encephaloscope  and  the 
whole  cavity,  but  not  tightly  packed.  Instead  of  a  gauze  dressing  a 
soft-rubber  drainage  tube  may  be  used,  the  tube  emerging  through  the 
trephine  opening. 

The  original  dressings  need  not  be  changed  for  four  or  five  days 
unless  the  drainage  is  profuse  and  the  dressing  requires  earlier  changing. 
The  packing  within  the  abscess  cavity  may  become  saturated  with 
exudate  and  give  rise  to  pressure  symptoms.  It  should  accordingly 
be  removed  at  once  and  a  new  packing  or  a  rubber  drainage  tube 
substituted.  The  gauze  packing  or  the  tube  is  gradually  shortened  at 
each  subsequent  dressing  so  that  it  should  not  act  as  a  hindrance  to 
the  natural  resumption  of  the  brain  of  its  normal  dimensions. 

Exploration  for  cerebellar  abscess  is  carried  out  as  in  temporo- 
sphenoidal  abscess  except  that  when  the  abscess  is  located  anteriorly 
and  in  the  deeper  part  of  the  cerebellar  hemispheres  it  is  safer  not  to 


320  REGIONAL   SURGERY 

use  a  knife  but  an  exploring  trocar  and  cannula.  The  Ballance  cannula 
is  so  constructed  that  it  may  be  left  in  position  after  the  abscess  has 
been  penetrated  and  evacuated. 

Treatment  and  subsequent  drainage  and  dressings  are  the  same  as 
in  temporo-sphenoidal  abscess. 

Meningitis. — This  is  fortunately  a  comparatively  rare  complication 
in  middle-ear  suppuration.  With  an  infection  of  low  virulence  the  on- 
set ma}"  be  insidious  and  manifested  by  irritability,  irregular  fever  and 
dull  headache.  The  latter  increases  in  severity  until  it  becomes  the 
most  prominent  symptom.  Headache  is  also  most  severe  in  cases  with 
acute  onset.  As  the  disease  progresses  there  will  be  delirium,  vertigo 
and  muscular  rigidity  of  the  neck,  strabismus,  nystagmus,  dilatation  of 
the  pupils,  optic  neuritis;  finally,  coma,  paralysis  of  the  extremities, 
bladder,  and  rectum. 

Treatment,  if  the  meningitis  is  diffuse,  will  be  without  avail.  If 
more  localized  the  bone  over  the  diseased  area  should  be  freely  removed 
and  the  secretion  washed  away  with  sterile  salt  solution  and  the  wound 
gently  packed  with  sterile  gauze. 

The  serum  treatment  of  otitic  meningitis  has  not  been  followed  by 
much  success. 


SECTION  XVII 

INFLAMMATORY  AFFECTIONS  OF  THE  NECK 

By 

J.   E.  THOMPSON,  M.  B.,  B.  S.,  F.  R.  C.  S.,   F.  A.  C.  S. 

Galveston,  Texas 

I.  ACUTE   INFLAMMATIONS 

A.  Pyogenic  Infections  of  the  Skin  and  Subcutaneous  Tissues.^ — 

Boils. — Infection  of  the  hair  folHcles,  usually  with  staphylococci,  is 
often  met  with,  especially  in  the  posterior  region  of  the  neck  at  the  upper 
part.  The  course  of  these  infections  differs  in  no  respect  from  fur- 
unculosis  in  other  parts  of  the  body  except  that  they  probably  cause 
more  discomfort  on  account  of  their  situation.  The  neighboring  lymph 
nodes  may  become  enlarged  and  abscesses  may  result.  When  this 
comphcation  occurs,  serious  local  and  constitutional  s^Tiiptoms  may 
develop.  Owing  to  the  numerous  hair  follicles,  infection  spreads  easily 
from  the  original  focus  and  boil  after  boil  develops,  a  chronic  condi- 
tion of  furunculosis  resulting. 

Treatment. — Constitutional  remedies  are  indicated,  such  as  hygiene, 
attention  to  the  bowels,  iron,  arsenic,  etc.  Locally,  the  same  treat- 
ment is  used  as  for  boils  occurring  in  other  parts  of  the  body,  such  as 
evulsion  of  the  hair  and  destruction  of  the  initial  focus  with  the  cautery, 
or  injection  of  carbolic  acid  followed  by  careful  dressing  to  avoid  in- 
fection of  other  follicles.^  If  cases  are  seen  later,  the  focus  may  be 
lanced  or  may  be  allowed  to  open  spontaneously.  It  is  essential  to 
protect  the  surrounding  hair  follicles  from  infection,  and  if  fomenta- 
tions aroused,  the  surrounding  parts  should  be  protected  carefully  from 
the  purulent  secretion  by  smearing  them  with  carbolized  vaseline.  If 
the  lymphatic  nodes  suppurate  they  should  be  incised  promptly  to 
avoid  the  possibility  of  deep  cervical  cellulitis. 

Carbuncles. — The  origin  of  these  infections  varies.  Some  un- 
doubtedly appear  to  result  from  infection  of  hair  follicles,  but  others  are 
caused  probably  by  septic  embolisms  of  the  subcutaneous  arteries.  The 
infection  occupies  the  subcutaneous  tissue  and  the  skin  is  involved 
secondarily.  The  inflamed  focus  is  hard  and  poorly  defined  from  its 
inception.     Necrosis  of  tissue  occurs  early  and  it  may  spread  rapidly, 

'  Bier's  suction  hyperaemia  is  valuable. — Editor. 
21  321 


32  2  REGIONAL   SURGERY 

sometimes  occupying  a  very  large  area  of  the  neck,  reaching  occasion- 
ally from  the  occiput  above  to  the  shoulder  blades  below  and  extend- 
ing laterally  as  far  as  the  sterno-mastoid  muscles.  In  depth  it  may 
reach  the  laminae  of  the  vertebrae  and  destroy  them,  laying  bare  the 
dura  mater.  The  constitutional  sy?nptoms  may  be  very  severe.  The 
temperature  is  often  elevated  to  105°  and  the  pulse  is  very  rapid.  Symp- 
toms of  septicaemia  may  follow  and  the  patient  may  succumb.  The 
prognosis  is  very  unfavorable  in  patients  affected  with  diabetes  or 
Bright's  disease. 

Treatfnent. — Many  of  the  mild  cases  can  be  treated  by  fomentations, 
assisted  by  crucial  incisions  to  relieve  pain  and  liberate  the  discharges. 
In  cases  which  do  not  improve  rapidly  or  in  which  the  constitutional 
and  local  symptoms  are  severe  from  the  beginning,  energetic  and 
heroic  treatment  is  imperative.  A  general  anaesthetic  should  be  given, 
if  not  contraindicated,  and  incisions  made  into  the  necrotic  mass  free 
enough  to  enable  the  surgeon  to  remove  the  dead  tissue  completely. 
The  living  tissue  at  the  bottom  of  the  wound  should  afterward  be 
cauterized  carefully  to  prevent  septic  absorption  from  the  raw  surface. 

B.  Pyogenic  Infections  of  the  Subfascial  Planes  of  Connective 
Tissue. — Deep  pyogenic  infections  may  manifest  themselves  in  one  of 
two  ways:  (i)  In  the  form  of  an  acute  (Edema  which  terminates  rapidly 
in  suppuration  (Ludwig's  angina);  (2)  in  the  form  of  acute  abscesses 
resulting  from  the  destruction  of  lymphatic  glands,  or  rarely  as  the 
result  of  wounds,  accidental  or  operative.  The  former  is  in  the  nature 
of  an  acute  lymphatic  infection  of  intense  virulence,  requiring  prompt, 
free  incisions,  whereas  the  latter  is  usually  more  chronic  in  its  course 
and  can  be  treated  by  more  leisurely  and  conservative  measures. 

Ludwig's  Angina  (Submaxillary  Cellulitis). — This  disease  was  de- 
scribed first  by  Ludwig  in  1836,  since  which  time  it  has  received  care- 
ful attention.  The  infection  which  goes  by  the  name  of  Ludwig's 
angina  originates  in  the  submaxillary  region  as  a  distinct  phlegmon,  sec- 
ondary usually  to  a  primary  focus  in  the  interior  of  the  mouth,  such  as 
an  ulcer  or  an  alveolar  abscess.  Careful  bacteriological  examination 
of  the  discharges  from  a  number  of  cases  has  shown  that  many  varieties 
of  organisms  are  capable  of  producing  this  disease.  In  the  majority  of 
cases  streptococci  have  been  found,  but  quite  frequently  staphylococci 
and  even  colon  bacilli  are  the  causes.  The  first  manifestation  of  deep 
infection  is  seen  in  the  submaxillary  region,  the  parts  rapidly  be- 
coming oedematous  and  swollen.  The  infection  is  usually  one-sided, 
but  occasionally  it  may  be  bilateral.     There  is  marked  swelling  be- 


INFLAMMATORY   AFFECTIONS    OF   THE   NECK  323 

neath  the  jaw  reaching  as  low  as  the  hyoid  bone,  the  tongue  is  pushed  up- 
ward into  the  mouth  and  the  subh'ngual  ridge  is  unduly  prominent.  The 
jaws  are  fixed  and  the  patient  is  unable  to  open  his  mouth.  The 
secretion  of  saliva  is  increased  and  the  breath  becomes  foul.  Occasion- 
ally the  source  of  the  infection  is  plain,  such  as  necrosis  of  the  jaw, 
alveolar  abscess  or  ulcer  of  the  tongue  or  floor  of  the  mouth,  but  quite 
frequently  no  such  source  can  be  discovered.  The  tongue  is  enlarged 
and  oedematous  and  fills  the  mouth  so  completely  that  breathing  may 
be  difficult.  The  oedema  may  spread  to  the  glottis  with  fatal  results. 
As  time  passes  the  infection  spreads  from  the  submaxillary  region  into 
the  cellular  planes  of  the  neck  and  passes  rapidly  downward  along  the 
course  of  the  carotid  vessels.  The  constitutional  symptoms  are  very 
severe.  There  is  high  fever  and  often  severe  rigors.  The  type  ap- 
proaches that  of  acute  septicaemia,  which  is  often  the  cause  of  death  in 
cases  that  do  not  receive  prompt  surgical  attention.  The  prognosis 
is  very  grave.  There  is  no  tendency  to  localization,  and  death  will 
occur  in  the  majority  of  cases  before  the  abscesses  can  open  spon- 
taneously. The  mortahty  in  neglected  cases  is  always  high,  death 
occurring  from  septicaemia  or  from  septic  pneumonia. 

Treatment. — As  soon  as  the  case  is  recognized  a  general  anaesthetic 
must  be  given  and  free  incisions  made  into  the  inflamed  area.  The  best 
incision  is  one  that  lays  bare  the  whole  submaxillary  triangle.  It  must 
be  carried  from  the  symphysis  of  the  jaw  down  to  the  hyoid  bone, 
curving  outward  and  upward  until  it  reaches  the  sterno-mastoid  muscle 
opposite  the  angle  of  the  jaw.  The  flap  must  be  thrown  upward  until 
the  submaxillary  salivary  gland  is  laid  bare.  Sometimes  pus  is  found 
in  the  fascial  space  in  which  this  gland  lies  and  in  some  rare  cases  the 
gland  has  been  found  necrotic.  If  the  infection  has  passed  into  the 
deep  cervical  planes,  an  incision  must  be  carried  from  the  posterior 
end  of  the  first  cut  downward  along  the  anterior  border  of  the  sterno- 
mastoid  as  far  as  the  sternum.  The  carotid  packet  of  vessels  must 
be  followed  to  the  lowest  point  of  infection,  which  must  be  carefully 
packed  with  iodoform  gauze.  The  upper  parts  of  the  incision  must  be 
left  wide  open  and  drains  carefully  placed  to  insure  free  exit  of  dis- 
charges. Afterward,  antiseptic  fomentations  should  be  employed. 
As  in  other  forms  of  sepsis,  careful  constitutional  treatment,  such  as 
diet,  tonics,  etc.,  is  necessary.  The  effects  of  prompt  surgical  measures 
are  often  magical.  The  writer  has  seen  cases  showing  marked  sep- 
ticaemic  symptoms  with  profound  depression  recover  so  rapidly  that 
they  were  able  to  sit  up  24  hours  after  the  operation. 


324  REGIONAL    SURGERY 

Acute  Abscesses  of  the  Neck. — Acute  pyogenic  infections  of  the 
deeper  planes  of  the  neck  usually  result  from  the  destruction  of  lym- 
phatic glands,  by  organisms  which  have  gained  access  from  the  mouth 
and  tonsils  during  the  course  of  scarlet  fever  and  other  exanthemata. 
Other  sources  of  infection  are  wounds  and  infections  of  the  mouth, 
scalp,  face  and  neck.  As  a  rule  the  deep  glands,  which  lie  along  the 
internal  jugular  vein  under  the  upper  part  of  the  sterno-mastoid,  suffer, 
and  the  resulting  abscess  occupies  this  situation  under  the  deep  cervical 
fascia.  More  rarely  they  may  occur  in  the  submaxillary  region.  Oc- 
casionally the  retropharyngeal  glands  may  be  affected,  the  purulent 
collection  in  this  case  lying  behind  the  pharynx  and  causing  a  swelKng 
which  can  be  seen  and  felt  between  the  fauces.  Peritonsillar  abscesses 
form  a  class  by  themselves,  the  pus  in  this  affection  spreading  into  the 
deeper  planes  of  the  neck  without  the  intermediation  of  the  lymphatic 
glands. 

Pathology. — The  cause  of  suppuration  is  almost  invariably  a 
staphylococcus,  and  hence  the  tendency  is  for  the  collection  to  become 
localized.  In  rare  instances  streptococci  are  present  and  the  resulting 
infection  is  more  diffuse  and  of  graver  import. 

Symptoms. — Following  a  primary  throat  affection,  the  deep  lym- 
phatic glands,  already  enlarged  and  painful,  show  evidences  of  more 
severe  inflammation.  The  soft  parts  around  them  become  oedematous 
and  they  become  lost  in  an  area  of  deep  induration.  The  natural  out- 
lines of  the  neck  become  obliterated  (Fig.  163).  The  patient  complains 
of  severe  pain  and  a  feeling  of  tension.  The  temperature  is  high  and  the 
pulse  is  rapid.  Rigors  are  not  infrequent.  Fluctuation  cannot  be  de- 
tected until  late  in  the  course  of  the  disease.  As  the  case  progresses  a 
periglandular  abscess  forms  which  increases  in  size  rapidly.  It  may 
spread  downward  and  upward  with  great  speed,  following  the  course  of 
the  carotid  vessels,  or  it  may  remain  circumscribed  and  penetrate  gradu- 
ally through  the  deep,  cervical  fascia  toward  the  surface.  As  would  be 
expected,  streptococcic  infections  are  more  diffuse  than  those  caused  by 
staphylococci.  If  the  case  is  neglected,  very  serious  results  may  follow. 
Locally,  the  whole  neck  may  be  infiltrated  as  low  as  the  mediastinum. 
Constitutionally,  septicaemia  may  result. 

Treatment. — The  abscess  should  be  evacuated  as  early  as  possible. 
Under  no  circumstances  should  we  wait  for  fluctuation.  In  the  early 
stages,  Hilton's  method  of  opening  the  abscess  should  be  employed. 
Later,  free  incisions  may  be  necessary.  The  deep  fascial  planes  must  be 
opened  freely  at  all  hazards  and  drainage  tubes  carefully  placed  in  the 


INFLAMMATORY   AFFECTIONS    OF   THE    NECK 


325 


cavity.  If  the  infection  has  burrowed  along  the  carotid  vessels,  the 
path  of  the  infection  must  he  followed  to  its  termination  and  laid  open 
freely.  In  retropharyngeal  abscesses  it  is  preferable  in  the  early  stages 
to  open  them  through  an  incision  along  the  posterior  border  of  the  sterno- 
mastoid.  In  large  abscesses,  with  symptoms  of  urgent  dyspnoea,  the 
pharyngeal  route  is  quicker  and  safer. 


Fig.  163. — Abscess  of  neck  beneath  the  deep  cervical  fascia.     {Bryaiil  and  Buck's  Surgery.) 

II.  CHRONIC  INFLAMMATIONS 

As  the  lymphatic  glands  are  intimately  associated  with  most  of 
the  chronic  inflammatory  affections  of  the  neck,  it  seems  the  proper 
place  to  describe  their  anatomy  in  detail. 

Anatomy  of  the  Lymphatics  of  the  Head  and  Neck. — The  following 
description  follows  closely  the  classical  one  given  by  Poirier  and  Cuneo. 

The  lymphatic  nodes  of  the  neck  may  be  described  as  forming  a 
rough  circle  or  collar  placed  at  the  junction  of  the  head  and  neck,  from 
each  side  of  which  a  vertical  chain  stretches  downward  along  the  in- 
ternal jugular  vein  as  far  as  the  upper  aperture  of  the  thorax.     The 


326 


REGIONAL   SURGERY 


Upper  glandular  circle  consists  of  the  following  groups  of  glands  (Figs. 
164  and  165): 

I.  The  Suboccipital  Group. — The  number  of  glands  in  this  group 
varies  from  one  to  three.  They  usually  rest  on  the  insertion  of  the  com- 
plexus  muscle  just  outside  the  border  of  the  trapezius.  Ricord's  gland, 
formerly  considered  of  such  importance  in  cases  of  suspected  syphilis,  be- 
longs to  this  group.  These  glands  drain  the  occipital  portion  of  the 
scalp  and  their  efferent  vessels  open  into  the  upper  glands  of  the  sub- 
sterno-mastoid  group. 


Anterior  auricular  — 

Parotid  glands           '  ^\ 
(superficial  a. deep) -"Siii^-ir^ZI^;;;^  MTvi '■^'• 

Buccinator  «land_ t\.  ~    ^&7i 

(rare)  ^  -..  -^      ,  .„ . 


Supramandib 
glands  ( 


Submaxillary 

Submental 
Submaxillary  Salivary 
gland 
Facial  nerve  cervical'^ 

branch 
External   jugular  \em 


_  Suboccipital 
Posterior  auricular 


Parotid  gland 


'rm[I.Z:=^  External  jugular  glands 


Accessory  nerve 
Superficial  glands  of  occipital  triaingle 


nferior  deep  cervical  glands 


Fig.  164. — {Keiller. 


2.  The  Mastoid  Group. — The  number  is  usually  limited  to  two, 
which  lie  on  the  insertion  of  the  sterno-mastoid  into  the  mastoid  proc- 
ess. They  are  very  common  in  children,  but  rare  in  adults.  They 
drain  the  temporal  portion  of  the  scalp,  the  posterior  surface  of  the 
auricle,  except  in  the  lobule,  and  the  posterior  surface  of  the  external 
auditory  meatus.  The  efferent  vessels  open  into  the  upper  glands  of 
the  substerno-mastoid  group. 

3.  The  Parotid  Glands. — These  glands,  which  are  numerous,  may 
lie  either  (a)  just  beneath  the  parotid  fascia  (superficial  glands),  or  (b) 


INFLAMMATORY   AFFECTIONS    OF   THE    NECK 


327 


be  placed  deeply  in  the  substance  of  the  gland  (deep  glands).  The 
former  are  usually  found  in  front  of  the  tragus  and  one  of  their  number 
is  often  quite  prominent  (the  preauricular  gland)  if  enlarged.  The 
latter  are  scattered  usually  along  the  branches  of  the  temporo-facial 
vein,  and  are  not  confined  to  any  part  of  the  parotid  gland.  The 
afferent  vessels  drain  the  anterior  surface  of  the  ear  and  the  external 
auditory  meatus,  the  anterior  portion  of  the  temporal  region  of  the 


Retracting  parotid  gland-^^ — JL_ 

r 

Posterior  facial  vein 

Anterior  facial     vein  - 
Submaxillary  lymph  gland: 

Common  facial  vein  — 
Submental  lymph  glands- 
Submaxillary  "Salivary  gland 

Infrahyoid  gland  - 
ouperior  deep  cervicar  lymph 
Glands   (medial  group) 

Omohyoid  - 
Prelaryngeal  gland 

Inferior   deep    cervical  gland; 
medial  group  ° 

Pretracheal  glands 


Superior  dcepcervical;  lateralgroupofglands 
External  jugular  vein 


Ju^ulodigastnc  orTonsillargland. 
Accessory  nerve 

Sterno-mastoid  reflected 


internal  ju.gular  vein 

Brachial  plexus 

Inferior  deepcervicalglands 
lateral  group 


Fig.  165. — {Kcillcr.) 


scalp,  the  frontal  region  of  the  scalp,  both  eyelids  and  the  bridge  of 
the  nose.  The  eflferent  vessels  empty  into  the  upper  glands  of  the 
substerno-mastoid  group. 

[During  operation  it  is  an  anatomical  impossibility  to  dissect  all 
the  glands  from  the  parotid  without  destroying  it  and  cutting  the 
branches  of  the  facial  nerve.  On  this  account  malignant  metastases 
in  these  nodes  necessitate  complete  extirpation  of  the  parotid.] 

In  addition  to  the  glands  above  described,  others  are  found  lying 


328  REGIONAL  SURGERY 

between  the  parotid  and  pharynx  in  the  lateral  pharyngeal  space  in 
contact  with  the  internal  jugular  vein  and  internal  carotid  artery.  To 
them  the  name  of  subparotid  nodes  has  been  given.  Their  afferent 
vessels  drain  the  nasal  fossae,  the  nasopharynx  and  the  Eustachian  tube, 
the  efferent  vessels  open  into  the  upper  glands  of  the  ^ubsterno-mastoid 
group. 

4.  The  submaxillary  glands  vary  in  number  from  three  to  six. 
They  He  under  cover  of  the  lower  border  of  the  jaw,  the  anterior  ones 
resting  on  the  mylohyoid  and  the  posterior  on  the  submaxillary  sali- 
vary gland.  The  posterior  node  of  this  chain  is  often  large  and  is  in 
close  contact  with  the  facial  vein.  The  anterior  nodes  are  usually 
deeply  placed  under  cover  of  the  jaw.  The  afferent  vessels  drain  the 
nose  (except  the  bridge)  the  cheek,  the  upper  lip,  the  external  part  of 
the  lower  lip,  almost  the  whole  of  the  gums,  and  the  anterior  third  of 
the  lateral  border  of  the  tongue.  The  efferent  vessels  pass  down- 
"ward  over  the  hyoid  bone  and  open  into  the  lower  glands  of  the  sub- 
sterno-mastoid  group  about  the  level  of  the  upper  border  of  the  thyroid 
cartilage.  Some  few  of  the  trunks  may  pass  still  lower  and  open  into 
a  gland  situated  where  the  omohyoid  crosses  the  internal  jugular 
vein.  (Supraomohyoid  gland).  In  the  afferent  vessels  of  the  sub- 
maxillary glands  we  occasionally  meet  with  some  small  glands,  usually 
along  the  course  of  the  facial  vein.  They  are  often  divided  into  three 
groups:  (i)  the  supramaxillary  group.  The  lowest  of  these  is  found  in 
contact  with  the  facial  vein  just  above  the  margin  of  the  jaw.  It  is 
quite  commonly  met  with  in  cancer  of  the  upper  lip.  (2)  The  buc- 
cinator group,  situated  on  the  buccinator  muscle,  is  more  rarely  met. 
(3)  A  superior  group  (very  rare)  consisting  of  two  or  three  glands 
occurring  along  the  groove  between  the  nose  and  cheek.  (Some  of 
these  glands  are  shown  in  dotted  outline  in  Fig.  164.) 

5.  The  Submental  Glands.- — Three  or  four  in  number,  are  situated 
deeply  in  the  space  between  the  two  anterior  bellies  of  the  digastric 
muscles.  They  lie  in  a  single  row  reaching  from  chin  to  the  hyoid 
bone.  Their  afferent  vessels  drain  the  middle  portion  of  the  skin  of  the 
lower  lip  and  the  chin,  the  corresponding  portion  of  the  alveolar  border 
of  the  lower  jaw,  the  floor  of  the  mouth  and  the  tip  of  the  tongue.  The 
efferent  vessels  pass  in  two  directions.  Some  open  into  the  submaxillary 
glands.  The  others  pass  downward  over  the  hyoid  bone  and  open  into 
the  gland  above  mentioned  situated  where  the  internal  jugular  vein  is 
crossed  by  the  omohyoid  (supraomohyoid  gland). 

These  five  groups  of  glands  just  described  form  the  cervical  collar 


INFLAMMATORY   AFFECTIONS    OF   THE   NECK  329 

or  circle,  and  from  the  opposite  sides  of  this  circle  the  substerno-mastoid 
glands  pass  down  along  the  jugular  vein,  hanging  as  it  were,  like  cords 
from  a  hoop.  Almost  bisecting  the  upper  cervical  circle  is  the  retrophar- 
yngeal glandular  group.  This  group  consists  usually  of  two  glands  only, 
situated  behind  the  posterior  pharyngeal  wall  and  in  front  of  the  lateral 
masses  of  the  atlas.  Their  afferent  vessels  drain  the  mucous  membrane 
of  the  nasal  fossae  and  the  cavities  connected  with  it,  the  nasopharynx, 
and  the  Eustachian  tube.  The  efferent  vessels  pass,  some  in  front, 
others  behind  the  great  vessels  of  the  neck  and  open  into  the  upper 
glands  of  the  substerno-mastoid  group. 

The  Descending  or  Lateral  Cervical  Chains. — On  each  side  of  the 
neck,  situated  under  the  deep  cervical  fascia  and  intimately  incorpor- 
ated with  its  layers,  the  deep  cervical  chain  of  lymphatic  glands  reaches 
from  the  level  of  the  transverse  process  of  the  atlas  above  to  the  upper 
aperture  of  the  thorax  below.  (Branching  off  from  it  are  some  acces- 
sory chains  of  more  or  less  importance  which  will  be  described  later.) 
The  chain  consists  of  a  large  number  of  glands  and  follows  the  course 
of  the  internal  jugular  vein.  The  upper  part  of  the  chain  Hes  under 
the  sterno-mastoid  muscle,  the  lower  part  lies  in  the  subclavian 
triangle.  It  may  be  divided  conveniently  into  two  groups,  viz.,  the 
substerno-mastoid  and  the  supraclavicular  groups. 

I.  The  Substerno-mastoid  Group. — The  glands  of  this  group  reach 
from  the  level  of  the  transverse  process  of  the  atlas  above  to  the  junc- 
tion of  the  internal  jugular  and  subclavian  veins  below.  The  glands 
are  very  numerous  above,  but  are  rarely  found  below  a  point  where 
the  omohyoid  crosses  the  internal  jugular  vein.  They  may  be  divided 
conveniently  into  the  two  following  subsidiary  groups: 

1.  An  external  group  which  is  found  along  the  posterior  border  of  the 
sterno-mastoid  muscle.  The  glands  of  this  group  are  intimately  con- 
nected with  the  branches  of  the  cervical  plexus  and  lie  on  the  splenius 
capitis,  the  levator  anguli  scapulae  and  the  scalenus  medius  muscles, 
to  which  they  are  firmly  bound  by  the  deep  cervical  fascia.  They 
blend  with  the  glands  in  the  subclavian  triangle.  Their  afferent 
vessels  come  mainly  from  the  occipital  group  of  glands  and  the  skin  of 
the  posterior  portion  of  the  neck  below  them. 

2.  An  internal  group  which  lies  under  the  sterno-mastoid  muscle 
in  close  contact  with  the  internal  jugular  vein  and  its  branches.  The 
upp'er  glands  of  this  group  are  very  constant  and  into  them  drain  the 
vjessels  from  the  glands  forming  the  cervical  collar  and  the  retropharyn- 
geal glands.     One  of  these  upper  glands  deserves  a  special  description. 


33<^ 


REGIONAL   SURGERY 


It  is  probably  the  most  constant  of  all.  It  lies  in  a  triangle,  one  side  of 
which  (the  upper)  is  formed  by  the  posterior  belly  of  the  digastric 
muscle,  the  other  two  sides  being  formed  by  the  fork  made  by  the  junc- 
tion of  the  linguo-facial  vein  and  the  internal  jugular.  Cecil  Leaf,  in 
1898,  named  it  the  "jugulo-digastric  gland''  and  this  is  probably  the 


Anterior  aurlculai' 

Saperficial  facial  \ 
(very  inconstant)  I 
Parotid.— 

5ubnvax\Uary 

Submental  — 

Infrahyoid 

Prelaryngeal 

ParatracKeal 

Left  jugular  trunk 
Richt  Jugular  truriK 
^iel^  -•-?—■•--  -■- 


Rignt  subclavion  trunk     - 
Bronchomediastinal  duct        f^' 


Bronchomediastinal  duct 
Left  stcrnat  cKaln. 
Rl$ht  sternal  chaxn 

1       A 


Posterior  auricular 

Suboccipital 

ugulo  digastric  (leaf) 
Superior  deep  cervical 
lateral  group 

Superior. deep  cervical 

medtal    group- 
Superficial  Jlands  of 
occipital    triangle 

Inferior  deep  cervical  or 

supraclavicular 
.ntraclavlcular 
Subclavian    trunk 
Delto    pectoral 
Subpectoral 
Delto  pectoral 
lympKotlcs 
Interpectoral 

Lateral  oxillary 

■rCentral  axillary 

Supero  internal 

pect(rai 
Infero  external 

pectoral 
"Subscapular 


Fig.  166. — (Keiller,) 


best  anatomical  name.  Kiittner,  in  1898,  called  it  the  "Haupt" 
gland.  Wood,  in  1905,  finding  that  it  received  directly  all  the  lymph- 
atics from  the  tonsil  csiWed  it  the  "  tonsillar  gland."  Its  importance 
will  be  appreciated  when  we  remember  that,  in  addition  to  receiving  the 
efferent  trunks  draining  the  glands  above  it  in  the  vertical  chain,  it 
receives  directly  the  following:  (a)  the  efferent  trunks  from  the  tonsils 


INFLAMMATORY   AFFECTIONS    OF   THE   NECK  33 1 

and  the  contiguous  portions  of  the  palate  and  the  tongue  (Wood);  (b) 
all  the  basal  lymphatics  of  the  tongue;  (c)  the  greater  number  of  the 
marginal  lymphatics  of  the  tongue,  and  (d)  some  of  the  central  lym- 
phatics of  the  tongue.  The  anatomical  position  of  this  gland  can 
be  studied  in  Figs.  165  and  166.  Under  ordinary  circumstances  the 
lowest  gland  of  this  internal  group  is  placed  at  the  point  where  the  omo- 
hyoid crosses  the  internal  jugular  vein.  This  gland,  to  which  the  name 
'' supraomohyoid"  has  been  given,  is  very  constant  and  is  very  important, 
because  in  addition  to  receiving  the  efiferent  trunks  from  the  glands 
above  it,  it  receives  lymph,  directly,  from  the  following  sources:  (a) 
from  the  lowest  submental  gland;  (b)  some  of  the  central  lymphatics 
of  the  tongue;  (c)  (rarely)  from  some  of  the  lymphatics  draining  the 
lower  lip.  Butlin  writing  in  1905  (Brit.  Med.  Journ.,  Feb.  11),  empha- 
sized the  importance  of  this  gland  and  advised  its  removal  as  a  routine 
procedure  in  all  cases  of  cancer  of  the  tongue. 

This  internal  group  is  without  doubt  the  most  important  in  the 
neck.  In  addition  to  receiving  the  efferent  trunks  from  the  glands  form- 
ing the  cervical  collar,  it  receives  direct  lymphatic  flow  from  the 
following  parts:  the  tongue,  the  nasal  cavities,  palate,  larynx,  oesophagus 
pharynx,  cervical  portion  of  trachea  and  thyroid  gland.  All  the  ef- 
ferent lymphatics  from  the  internal  group  pass  downward  as  one  or 
two  vessels,  into  which  the  efferent  vessels  of  the  supraclavicular  glands 
join,  forming  a  main  trunk  known  as  the  jugular  trunk,  which  joins  the 
thoracic  duct  on  the  left  side,  while  on  the  right  side  it  opens  separately 
into  the  junction  of  internal  jugular  and  subclavian  veins.  (See 
Fig.  166.) 

II.  The  Supraclavicular  Glands. — This  group  of  glands  lies  in  the 
posterior  triangle  of  the  neck  and  is  formed  by  a  number  of  glands 
which  are  continuous  above  with  those  forming  the  external  group  of 
the  deep  cervical  chain.  The  upper  ones  lie  on  the  splenius  capitis, 
the  levator  anguh  scapulae  and  the  scalenus  medius  muscles,  and  are 
closely  connected  with  the  descending  branches  of  the  cervical  plexus  of 
nerves.  The  lower  ones  lie  on  the  omohyoid  muscle  and  are  intimately 
connected  with  the  termination  of  external  jugular  vein,  the  descending 
branches  of  the  cervical  plexus  and  the  upper  branches  of  the  brachial 
plexus.  The  afferent  vessels  are  derived  from  the  following  sources: 
(i)  the  skin  of  the  occipital  region  of  the  scalp  and  the  posterior  part  of 
the  neck;  (2)  the  skin  of  the  pectoral  and  mammary  regions;  (3)  some 
of  the  cutaneous  lymphatics  of  the  arm  which  accompany  the  cephalic 
vein  (which  occasionally  pass  over  the  clavicle  instead  of  emptying  into 


332  REGIONAL   SURGERY 

the  subclavian  glands) ;  (4)  some  of  the  axillary  glands,  especially  those 
forming  the  humeral  chain.  Special  attention  should  be  called  to  the 
possibility  of  infection  of  these  glands  in  cancer  of  the  breast,  following 
implication  of  the  skin  or  axillary  glands.  Pyogenic  infections  of  the 
radial  side  of  the  upper  extremity  are  occasionally  followed  by  direct 
infection  of  this  group.  The  efferent  vessels  of  this  group  unite  with 
those  of  the  substerno-mastoid  glands  to  form  the  jugular  trunk  which 
(as  mentioned  above)  opens  into  the  thoracic  duct  on  the  left  side  and 
directly  into  the  junction  of  the  subclavian  and  internal  jugular  veins 
on  the  right. 

It  will  be  seen  from  the  above  description  that  the  lowest  glands 
of  the  lateral  cervical  chain  are  in  close  connection  with  the  supraclav- 
icular group  and  that  infections  can  pass  from  one  group  to  the  other. 
It  has  also  been  pointed  out  that  lymphatic  trunks  pass  from  the  axillary 
glands  to  the  supraclavicular  group  and  that  separate  lymphatic  vessels 
draining  the  arm  (outer  side)  and  the  skin  over  the  pectoral  muscles 
drain  into  this  group.  In  this  manner  the  upper  extremity  and  the 
mammary  gland  are  brought  in  as  tributaries.  It  is  necessary,  how- 
ever, to  correct  in  a  most  emphatic  manner  loose  statements  that  the 
cervical  and  axillary  lymphatics  drain  into  the  mediastinal  glands. 
There  is  never  any  direct  connection.  All  infectious  material  that  filters 
through  these  glands  passes  directly  into  the  venous  circulation  either 
by  way  of  the  thoracic  duct  or  by  separate  lymphatic  trunks  which  open 
separately  into  the  subclavian  vein.  In  Fig.  166  these  points  have 
been  clearly  pictured. 

In  addition  to  the  groups  forming  the  lateral  chain  described  above, 
certain  accessory  chains  may  be  mentioned.     There  are  three  in  number: 

1.  The  external  jugular  chain,  consisting  of  two  or  three  glands,  is 
found  along  the  vein  of  the  same  name.  The  afferent  trunks  drain  the 
ear  and  parotid  region  and  the  efferent  trunks  open  into  the  upper 
glands  of  the  deep  cervical  region. 

2.  The  superficial  anterior  cervical  chain  consisting  of  two  or  three 
glands  is  occasionally  found  along  the  anterior  jugular  vein. 

3 .  The  Anterior  Deep  Cervical  Chain. — Scattered  glands  are  occasion- 
ally found  beneath  the  subhyoid  muscles  in  front  of  the  trachea  and 
larynx. 

Lastly,  attention  must  be  called  to  the  presence  of  small  glands  which 
have  been  spoken  of  as  interrupting  glandular  nodules.  They  are  more 
often  met  with  along  the  course  of  the  lingual  lymphatics  and  occur  usu- 
ally in  two  situations: 


INFLAMMATORY   AFFECTIONS    OF   THE    NECK  333 

1.  On  the  in  tralingual  or  central  trunks  lying  in  the  substance  of  the 
tongue  near  its  root,  between  the  two  geniohyoglossi  muscles. 

2.  On  the  marginal  or  lateral  lingual  trunks.  The  usual  situation 
is  under  the  submaxillary  gland,  on  the  outer  surface  of  the  hyoglossus 
muscle,  along  the  course  of  the  Ungual  vein.  (This  glandular  mass  was 
described  by  Butlin,  loc.  cit.  The  writer  has  met  with  it,  in  one  case  of 
cancer  of  the  tongue,  as  large  as  a  pea  and  infiltrated  with  epitheho- 
matous  material.) 

TUBERCULOSIS  OF  THE  LYMPHATIC  GLANDS 

The  lymphatic  glands  of  the  neck  are  more  often  affected  by  tuber- 
culosis than  any  other  part  of  the  body.  Approximately  about  90  per 
cent,  of  all  cases  of  lymph-gland  tuberculosis  occurs  in  this  region.  The 
disease.is  oftener  seen  between  the  ages  of  16  and  20  than  at  any  other 
period  of  life.     It  is  very  rare  before  the  second  year  of  life. 

Source  of  Infection. — It  is  probable  that  the  majority  of  cases  result 
from  infection  of  the  throat  with  tubercle  bacilli.  The  faucial  and 
pharyngeal  tonsils  are  often  affected  with  tuberculosis,  and  it  has  been 
found  that  tonsils  apparently  healthy  are  capable  of  harboring  tubercle 
bacilli.  Dieulafoy  inoculated  guinea-pigs  with  the  faucial  tonsils  of 
children  apparently  free  from  tuberculosis  and  produced  tuberculous 
disease  in  16.4  per  cent,  of  the  animals.  Tubercle  bacilli  have  also 
been  found  in  smears  taken  from  nasal  mucous  membrane  that  appeared 
to  be  healthy.  The  frequency  with  which  the  jugulo-digastric  gland 
(tonsillar  gland  of  Wood)  and  the  glands  in  its  vicinity  are  affected  with 
tuberculosis  favors  the  claim  that  the  tonsils  are  the  usual  port  of  en- 
trance. Still  it  must  be  remembered  that  infection  of  any  part  of  the 
buccal  or  nasal  cavities  such  as  may  result  from  carious  teeth,  or  from 
ulcers  of  the  tongue  or  gums  may  irritate  the  glands  and  leave  them  less 
resistant  to  the  growth  of  tubercle  bacilli. 

Pathology. — In  the  early  stages  the  glands  may  show  merely  a  h>per- 
plasia.  They  are  enlarged  and  surrounded  by  a  thickened  capsule,  and 
often  keep  their  original  shape.  On  section  they  appear  to  be  firm  and 
of  a  pink  color.  Microscopically,  there  may  be  an  increase  in  the  quan- 
tity of  fibrous  tissue  forming  the  tracebulae.  Tubercles  are  usually  en- 
tirely absent.  That  these  hyperplastic  glands  are  in  reality  tuberculous 
has  been  proved  by  Bios  who  succeeded  in  inoculating  guinea-pigs 
after  injecting  the  glandular  material  into  their  peritoneal  cavities. 
In  the  later  stages,  viz.,  those  of  caseation  and  liquefaction,  the  sepa- 


334 


REGIONAL   SURGERY 


rate  glands  of  an  affected  group  may  show  simultaneously  every  stage 
of  the  tuberculous  process  from  hyperplasia  to  complete  caseation. 
The  tendency  is  usually  toward  degeneration,  the  gland  substance  being 
gradually  destroyed  and  replaced  by  caseous  material  or  thick  tubercu- 
lous pus.  The  capsule  may  remain  intact  for  a  long  period  and  may  form 
a  strong  wall  for  the  abscess.  Occasionally  the  process  is  confined  to  a 
solitary  gland.  More  usually,  however,  the  infection  spreads  to  the 
glands  lower  in  the  series  and  after  a  time  the  clinical  picture  reveals  a 
chain  of  closely  connected  glands,  in  various  stages  of  destruction.  The 
inflamed  glands  contract  adhesions  to  the  surrounding  structures,  par- 
ticularly to  the  veins,  from  which  it  is  difficult  to  separate  them  during 
operation.  In  the  early  stages  the  disease  is  entirely  confined  to  the 
glandular  tissue.  At  a  later  period,  if  the  capsule  ruptures,  the  disease 
may  spread  into  the  surrounding  muscles,  such  as  the  sterno-mastoid, 
which  is  often  infiltrated. 

Symptoms  and  Course  of  the  Disease. — As  a  rule  the  enlargement 
is  insidious  and  chronic  from  the  beginning.  It  will  often  take  a  year  for 
a  gland  to  reach  the  size  of  a  walnut.  In  rare  cases  the  enlargement 
appears  acutely.  The  writer  observed  two  cases  of  this  nature  in  one 
family  apparently  caused  by  infection  of  the  tonsils.  In  one  case,  a 
boy  aged  15  months,  the  left  jugulo-digastric  gland  reached  the  size  of  a 
walnut  in  two  weeks.  It  was  removed  together  with  two  others  in  a 
hyperplastic  condition  (pretubercular).  A  few  weeks  after,  the  jugulo- 
digastric  glands  on  both  sides  of  the  neck,  in  another  child  of  the  same 
family,  a  girl  aged  five  and  one-half  years,  became  acutely  enlarged. 
Under  local  treatment  they  subsided  partially,  but  never  disappeared. 
Six  years  later  the  right  jugulo-digastric  swelled  up  again,  and,  resisting 
treatment,  underwent  caseation  which  necessitated  its  radical  removal. 
At  the  time  of  operation  four  or  five  glands  of  the  series  were  removed  but 
none  showed  evidences  of  tuberculous  infection. 

The  constitutional  symptoms  are  slight,  consisting  of  malaise  and 
irregular  low-grade  fever.  Not  uncommonly  the  patients  are  apparently 
robust  and  well  nourished.  The  group  of  glands  oftenest  effected  is 
the  upper  substerno -mastoid  group  whose  afferent  vessels  drain  the 
fauces  and  posterior  nares.  The  submaxillary  and  submental  glands 
probably  stand  next  in  order  of  frequency.  Occasionally,  the  infection 
localizes  itself  in  the  parotid  or  subparotid  group.  More  rarely,  some 
of  the  superficial  glands  along  the  external  jugular  or  anterior  jugular 
veins  may  be  diseased.  In  the  lower  part  of  the  neck  the  supraclavicu- 
lar group  is  not  infrequently  affected.     As  the  disease  progresses,  group 


INFLAMMATORY   AFFECTIONS    OF   THE   NECK 


335 


after  group  may  be  invaded  in  regular  sequence.  Thus,  primary  disease 
in  the  submaxillary  group  may  invade  the  substerno-mastoid  group 
and  pass  down  the  neck  along  both  its  internal  and  external  divisions 
until  it  reaches  the  supraclavicular  group  which  it  may  infect  by  direct 
contact.  The  final  appearance  of  the  anterior  and  posterior  triangles 
in  such  extensive  involvement  is  clearly  shown  in  Fig.  167.  In 
the  majority  of  cases  some  of  the  glands  first  affected  break  down 
and  discharge  externally,  so  that  necks,  extensively  involved,  often 


r 


'/  \ 


Fig.  167. — {Bryant  and  Buck.) 


show  numerous  sinuses  leading  down  to  the  caseous  foci.  The  termina- 
tions of  the  infection  vary  widely.  As  in  tuberculous  affections  else- 
where, the  inflammation  may  subside  and  the  glands  may  become 
greatly  reduced  in  size.  The  infection  is  rarely  completely  destroyed. 
It  is  usually  imprisoned  and  such  infected  glands  are  to  be  looked  upon 
as  a  serious  menace  because  the  inflammation  may  flare  up  at  any  mo- 
ment. Under  ordinary  circumstances  some  of  the  glands  are  very  apt 
to  break  down  and  suppurate  and,  if  the  skin  breaks,  pyogenic  infection 
is  added  and  the  resulting  destructive  process  may  continue  in  an  irregu- 


336  REGIONAL   SURGERY 

lar  manner  for  years.     Sometimes  it  may  appear  to  be  healing,  at 
others  to  be  spreading. 

Prognosis. — Rather  a  large  proportion  of  cases  die  eventually  of 
pulmonary  tuberculosis  (from  15  to  20  per  cent.)  while  others  contract 
tuberculosis  in  other  organs.  Dowd  quotes  Demmer's  statistics  of  the 
Jenner  Children's  Hospital  in  Berne.  In  29  years  work,  out  of  1692 
children  with  lymph  node  tuberculosis 


Developed  tuberculosis  of  lung 145         =   21.0  per  cent. 

Developed  tuberculosis  of  intestine 24 " 

Developed  tuberculosis  of  pia  mater 25 

Developed  tuberculosis  of  kidneys 6 

Developed  tuberculosis  epididymis 2  . 

Total =   29.2  per  cent. 


57=     8.2  per  cent. 


With  a  few  slight  differences  these  percentages  agree  with  those  given 
by  other  observers  and  indicate  fairly  accurately  the  destiny  of  patients 
affected  with  tuberculosis  of  the  lymphatic  glands. 

Diagnosis. — In  the  early  stages  the  diagnosis  is  very  difficult.  In 
delicate  children,  hyperplasia  of  the  lymphatic  glands  will  often  follow 
the  most  trivial  source  of  irritation,  such  as  peptic  ulcers  of  the  buccal 
cavity,  eruption  of  teeth,  etc.  The  enlargement  is  often  so  marked 
and  so  slow  to  subside,  that  strong  suspicion  of  a  tuberculous  involve- 
ment is  aroused.  Nevertheless,  these  glands  eventually  disappear 
under  suitable  treatment,  hygienic  and  medicinal.  Arsenic  given  as 
Fowler's  solution  will  often  cause  rapid  resolution  of  such  inflammations. 
Some  authors  are  inclined  to  look  upon  all  such  hyperplasias  as  being 
actually  tuberculous,  and  point  out  that  if  the  after  history  of  such 
patients  is  followed  carefully,  a  surprising  number  will  develop  tuber- 
culosis in  the  glands  previously  affected  or  in  some  internal  organ. 
While  admitting  that  many  hyperplasias  result  from  tuberculous  in- 
fection, it  is  not  wise  to  accept  such  an  extreme  view  of  the  question. 
It  has  been  suggested  (Dowd)  that  it  would  be  wise  to  remove  the  affected 
node  for  diagnostic  purposes,  and  there  can  be  no  rational  objection  to 
such  a  procedure  when  the  enlargement  resists  medicinal  treatment. 
A  crucial  test  could  be  made  by  inoculating  a  guinea-pig  with  an  emul- 
sion of  the  gland.  Hodgkift's  disease  may  simulate  tuberculosis.  In 
the  early  stages  of  Hodgkin's  disease,  before  the  constitutional  symp- 
toms are  evident,  a  differential  diagnosis  may  be  almost  impossible. 
In  both  diseases  the  glands  may  be  palpable  and  discrete.  In  the  later 
stages  the  glands  in  Hodgkin's  disease  usually  remain  separate  and 
feel  like  potatoes  under  the  skin,  while  in  tuberculosis  the  tendency  is 
to  fusion  as  the  result  of  periglandular  inflammation.     Still  later,  the 


INFLAMMATORY   AFFECTIONS    OF   THE   NECK  337 

severe  progressive  anaemia,  intermittent  fever,  and  gradual  weakness, 
which  accompany  Hodgkin's  disease  and  which  are  often  altogether  out 
of  proportion  to  the  apparent  lymphatic  involvement,  are  of  great 
value.  Enlargement  of  the  liver  and  spleen  are  also  of  value  as  pointing 
to  Hodgkin's.  Blood  counts  are  rarely  of  much  value.  They  vary  so 
much  in  both  diseases  as  to  be  of  little  pathognomonic  importance. 
From  lymphosarcoma  the  diagnosis  is  usually  easy.  The  extremely 
rapid  growth,  and  extensive  infiltration  of  all  surrounding  tissues,  is  so 
characteristic  of  lymphosarcoma  that  in  a  few  weeks  any  doubts  will  be 
cleared  up.  From  syphilis  the  diagnosis  should  be  easy.  In  this  dis- 
ease the  lymphatic  glands  are  only  sKghtly  enlarged.  They  are  hard 
and  discrete,  and  they  rarely  soften  or  suppurate. 

Treatment. — {a)  Medicinal  Treatment. — If  hygienic  measures  are  car- 
ried out  carefully,  medicinal  treatment  will  often  work  wonders  in 
lymphatic  tuberculosis.  It  is  not  necessary  to  send  our  patients  to  the 
seaside  to  accomplish  this,  although  in  the  British  Islands,  particularly, 
the  benefit  of  sea  air  has  been  insisted  upon.  The  outline  of  treatment 
is  as  follows :  Firstly,  all  sources  of  irritation  should  be  removed.  This 
includes  attention  to  digestion,  the  use  of  proper  food,  etc.;  attention  to 
the  teeth  and  gums; attention  to  the  tonsils, both  faucial  and  pharyngeal, 
and  to  the  nasal  cavity.  Secondly,  various  medicinal  agents  may  be 
used.  Foremost  among  these  is  arsenic.  Iron  and  iodide  of  potash 
are  of  great  value.  Thirdly,  local  applications  may  be  used,  such  as 
mercurial  ointment.  Strong  local  irritants  seem  irrational  as  they  must 
be  followed  by  a  hyperaemic  action  which  gives  the  lymphatic  glands 
more  work  to  do.     The  value  of  the  X-ray  is  somewhat  doubtful.^ 

{h)  Surgical  Treatment. — If  employed  early,  surgical  treatment  is 
undoubtedly  the  most  satisfactory  way  of  treating  tuberculosis  of  the 
lymphatic  glands.  The  strongest  argument  against  very  early  opera- 
tion lies  in  the  fact  that  the  majority  of  glands  in  the  so-called  hyper- 
plastic stage  will  disappear  entirely  under  careful  medical  treatment. 
And  yet  the  ease  of  performance  and  the  total  absence  of  danger  in  these 
early  operations,  added  to  the  brilUant  after  results,  is  a  very  strong 
argument  in  their  favor.  Perhaps  the  rational  view  to  take  of  the 
operative  question  is  to  reserve  operation  for  those  cases  that  resist 
intelligently  applied  hygienic  and  medicinal  measures  in  their  early 
stages.  This  course  would  give  all  cases  of  inflammatory  hyperplasia 
and  many  cases  of  actual  tuberculous  inflammation  a  chance  to  subside 
spontaneously.     If  during  the  course  of  convalescence  the  subsidence 

^  Hyperaemia  as  advised  by  Bier  is  often  of  great  value.     (Editor.) 


S^8  REGIONAL   SURGERY 

of  the  swelling  is  interrupted  from  time  to  time  by  a  flaming  up  of  the 
inflammatory  process,  operation  should  be  considered.  Exacerbations 
of  the  lymphatic  enlargement  at  irregular  longer  intervals  and  without 
adequate  cause  should  be  considered  as  operative  indications.  One 
of  the  strongest  arguments  in  favor  of  early  radical  operation  lies  in  the 
feehng  of  most  operators  that  they  have  no  cause  for  regret  after  the 
operation  is  completed,  because  not  only  do  they  find  that  the  glands 
attacked  are  extensively  diseased,  but  that  the  tuberculous  process  has 
extended  to  other  glands  in  the  neighborhood. 

The  character  of  operation  deserves  some  consideration.  The  su- 
periority of  radical  excision  over  curettement  is  acknowledged  at  the 
present  time  by  the  great  majority  of  surgeons.  Curettement  should 
be  reserved  for  cases  where  the  glands  are  so  extensively  affected  that 
complete  excision  is  impossible,  and  for  cases  where  removal  of  the 
broken-down  foci  is  imperative,  but  where  radical  operation  is  inadvis- 
able at  the  time  either  on  account  of  tuberculous  involvement  of  other 
organs  or  of  a  lowered  condition  of  general  health.  In  the  last  group 
of  cases  there  is  always  a  prospect  of  performing  the  radical  operation 
at  a  later  date.  The  results  of  radical  excisions  may  be  considered 
under  the  heads  of  early  and  late. 

The  early  results  are  very  satisfactory.  The  immediate  mortality 
is  almost  negligible  if  reasonable  care  is  taken  to  avoid  unjustifiable 
surgical  risks,  e.g.,  patients  affected  with  extensive  tuberculosis  in  other 
organs.  Early  pulmonary  tuberculosis  is  not  necessarily  a  contra- 
indication. The  patients  recover  very  rapidly  as  a  rule,  and  the  healing 
process  is  very  gratifying  if  care  is  taken  to  remove  all  infected  tissue. 
Delay  in  healing  can  often  be  traced  to  tissue  left  behind  in  the  wall  of 
an  infected  sinus. 

Late  Results. — The  value  of  statistics  on  the  final  state  of  these  pa- 
tients after  a  number  of  years  have  elapsed  is  diminished  by  the  impossi- 
bihty  of  tracing  a  large  proportion  of  them.  In  Dowd's  series  of  cases 
the  results  were  as  follows:  Apparent  cures  in  77.9  per  cent,  of  cases 
under  20  years  of  age,  and  in  57.2  per  cent,  of  cases  over  20  years  of 
age.  He  also  quotes  from  various  reports  that  out  of  1273  cases,  ob- 
served from  various  periods  of  from  i  to  16  years,  there  were  recorded 
as  cured  57.65  per  cent.;  as  having  local  recurrence  28.84  P^r  cent.;  as 
having  died,  mostly  from  tuberculosis,  13.51  per  cent.  There  can  be 
no  doubt  that  if  all  the  cases  operated  on  could  be  followed,  the  per- 
centage of  deaths  from  tuberculosis  in  other  organs  would  be  higher 
than  usually  estimated. 


INFLAMMATORY   AFFECTIONS    OF   THE   NECK  339 

CHRONIC  INFLAMMATION 

Actinomycosis  of  the  Neck. — The  ray  fungus  which  is  the  cause  of 
this  disease  enters  the  tissues  of  the  neck  either  by  direct  inoQulation  of 
the  skin  or  by  extension  of  the  disease  from  the  jaw  and  cheek,  or  from 
pharyngeal  and  tonsillar  actinomycosis.  The  disease  does  not  appear 
to  spread  by  the  way  of  the  lymphatic  channels.  Cases  rarely  come 
under  observation  in  the  early  stages.  The  course  of  the  disease  is 
fairly  rapid  and  when  well  developed  the  neck  presents  a  character- 


.....  ) 

Fig.  168. — Actinomj'cosis  of  the  neck.     {Lexer-Beian,  after  Illicit.) 

istic  appearance.  An  indurated  swelling  is  present,  the  margins  of 
which  are  imperfectly  demarcated  from  the  surrounding  healthy  tissue. 
The  skin  covering  the  swelling  is  thrown  into  prominent  indurated 
folds  like  the  furrows  of  a  ploughed  field  (Fig.  i68).  The  color  of  the 
skin  is  reddish  or  purplish.  In  some  places  fluctuating  spots  are 
present;  in  others,  sinuses  have  developed  from  which  pus  is  discharged 
containing  the  characteristic  yellow  granules  of  the  fungus.  The 
swelling  is  often  extensive,  interferes  materially  with  movements  and 
renders  swallowing  and  even  breathing  difficult.  The  constitutional 
symptoms  are  not  severe. 


340  REGIONAL   SURGERY 

The  diagnosis  is  often  difficult.  In  the  absence  of  the  characteristic 
fungus  or  the  branches  of  its  central  mycelium,  it  must  rest  oh  the  clin- 
ical findings.  It  may  be  difficult  to  distinguish  from  sarcoma  or  from 
syphiHs.  It  may  be  stated  here  that  iodide  of  potassium  will  often 
produce  marked  improvement  in  both  actinomycosis  and  syphilis. 
Perhaps  the  most  difficult  condition  to  distinguish  it  from  is  the  "lig- 
neous phlegmon"  of  the  neck. 

Prognosis. — The  prognosis  depends  on  early  recognition  and  prompt 
and  energetic  treatment.  In  neglected  cases  the  disease  may  riddle 
the  whole  neck  and  fatal  results  are  frequent. 

Treatment. — The  abscess  cavities  should  be  opened  freely,  and  the 
pus  evacuated.  Afterward  the  dead  tissues  should  be  scraped  away 
and  the  granulation  tissue  extensively  removed  with  a  sharp  curette. 
Finally,  the  cavity  should  be  disinfected  with  carbolic  acid  or  chloride 
of  zinc.  The  final  result  will  depend  entirely  on  the  thorough  curetting. 
Bevan  speaks  highly  of  the  value  of  copper  sulphate.  He  gives  it 
internally  in  quarter-grain  doses  and  irrigates  the  sinuses  with  a  i  per 
cent,  solution. 

Ligneous  Abscess  of  the  Neck. — {Syn.:  Phlegmon  Ligneuse;  Hoh- 
phlegmon). — This  disease,  described  by  Reclus  under  the  name  "phleg- 
mone  ligneuse,"  is  a  very  chronic  inflammatory  process  attacking  the 
lymphatic  glands  and  resulting  in  a  dense  wood-like  hardness  of  the 
deeper  tissues  of  the  neck.  The  cause  of  this  disease  varies  greatly. 
Many  different  pyogenic  organisms  have  been  found  and  no  one  seems 
to  be  specific.  It  has  been  suggested  that  the  disease  is  the  result  of 
an  attenuated  infection  capable  of  producing  and  keeping  up  prolonged 
inflammation  but  incapable  of  producing  pus. 

Symptoms. — The  source  of  the  inflammation  is  found  oftenest  in 
the  mouth  and  pharynx.  It  has  followed  mastoid  disease.  The  sub- 
maxillary lymph  nodes  are  usually  first  aftected.  They  become 
swollen  and  indurated.  There  is  not  much  pain.  The  periglandular 
tissues  are  next  involved,  the  result  being  that  all  the  subcutaneous 
tissues  become  fused  into  a  hard  board-like  mass.  The  boundaries 
of  the  induration  are  often  quite  sharply  defined  from  the  non-infected 
tissue.  There  are  practically  no  pain,  tenderness  or  fever.  There  is 
little  tendency  to  suppuration,  but  if  an  incision  is  made  into  the  inter- 
muscular spaces  a  purulent  exudate  may  be  found.  The  course  of  the 
disease  is  essentially  chronic  and  it  may  remain  stationary  for  long 
periods. 

Diagnosis. — The  diagnosis  is  very  difficult.     It  may  be  mistaken  for 


INFLAMMATORY   AFrECTIONS    OF   THE   NECK 


341 


lymphosarcoma,  for  secondary  cancer  or  for  actinomycosis.  The  first 
two  can  usually  be  ehminated  by  their  rapidity  of  growth  compared  to 
the  disease  in  question.  A  microscopic  examination  will  clear  up  the 
case  conclusively.  From  actinomycosis  the  diagnosis  is  less  easy, 
especially  so  as  it  is  occasionally  a  difficult  matter  to  demonstrate  the 
ray  fungus  in  true  cases  of  that  disease. 

Treatment. — As  spontaneous  cures  have  occurred  in  many  of  the 
reported  cases  and  as  active  treatment  appears  to  have  had  little  to  do 
with  the  results,  it  is  probably  better  to  treat  the  disease  from  a  palhative 
standpoint.  If  evidences  of  softening  and  pus  formation  are  present, 
free  incisions  should  be  made  into  the  indurated  areas. 

LYMPHOSARCOMA  AND  HODGKIN'S  DISEASE 

Extreme  types  of  these  diseases  differ  from  each  other  as  light  from 
darkness,  but  intermediate  types  approach  one  another  so  closely,  in 


Fig.  169. — (Lexer-Bevan.) 

their  local  manifestations  and  constitutional  symptoms,  that  it  is  very 
difficult  to  draw  a  hard  and  fast  boundary  line. 

Lymphosarcoma. — The  etiology  of  this  disease  is  as  obscure  as  is 
that  of  all  sarcomata.  The  upper  substerno-mastoid  group  of  glands 
is  most  often  affected,  but  the  disease  is  not  infrequent  in  the  parotid, 
the  lower  sterno-mastoid,  and  the  supraclavicular  groups.  Histo- 
logically the  growth  is  a  round-celled  sarcoma  often  of  a  pure  type. 
The  cells  are  very  numerous  and  are  contained  in  the  spaces  of  a  fine 
reticulum  covered  by  endothelium  (Fig.  169).  There  is  no  reproduc- 
tion of  lymphoid  tissue.  They  usually  occur  in  comparatively  young 
patients,  and  are  more  common  between  the  ages  of  20  and  30.     The 


342 


REGIONAL   SURGERY 


course  of  the  disease  is  very  characteristic.  In  the  very  early  stages, 
one  or  two  glands  can  be  palpated  as  discrete  enlargements.  The 
glands  grow  with  such  unusual  rapidity  that  in  a  few  weeks  they  may 
double  and  treble  their  size.  The  glands  soon  lose  their  nodular  and 
discrete  appearance  and  fuse  with  one  another  and  with  the  surrounding 
structures.  The  growth  rapidly  infiltrates  the  surrounding  tissues, 
and  flows  around  the  great  vessels  and  nerves  of  the  neck  embedding 


Fig.  170. — ^Lymphosarcoma  of  the  neck.     (Lexer-Bevan.) 


them  as  if  in  a  plaster  cast.  At  the  same  time  the  walls  of  the  blood- 
vessels may  become  infiltrated  and  portions  of  the  growth  may  fungate 
into  the  lumen  of  the  jugular  vein.  The  muscles  of  the  neck  may  be 
infiltrated  and  the  growth  may  infiltrate  and  surround  the  walls  of  the 
trachea  and  larynx  and  the  oesophagus  and  pharynx  (Fig.  170).  The 
growth  has  a  great  tendency  to  extend  to  the  surface,  and  to  infiltrate 
the  skin.     Fungation  and  sloughing  result  in  the  formation  of  enormous 


INFLAMMATORY   AFFECTIONS   OF   THE    NECK  343 

craters  which  often  bleed  profusely.  Some  cases  grow  so  rapidly  as  to 
infiltrate  one  side  of  the  neck  completely,  and  reach  the  stage  of  funga- 
tion  in  the  course  of  three  or  four  months.  The  writer  has  seen  one 
case  where  death  from  exhaustion  occurred  within  seven  months  of  the 
time  of  its  first  appearance. 

Symptoms. — In  the  early  stages  there  are  practically  no  symptoms 
other  than  the  presence  of  the  glandular  tumor.  Blood  examination 
shows  nothing  characteristic.  Later,  pressure  symptoms  make  their 
appearance.  In  the  neck  these  mainly  consist  of  interference  with 
breathing  from  pressure  on  the  trachea  or  larynx,  or  implication  of  the 
superior  and  recurrent  laryngeal  nerves.  Dysphagia  from  pressure 
on  the  gullet  is  not  uncommon  in  the  later  stages.  Pressure  on  the 
carotid  and  internal  jugular  rarely  gives  rise  to  trouble,  nor  does  impli- 
cation of  the  vagus  nerve  affect  the  heart  materially.  As  time  passes 
the  patient  becomes  weaker.  At  this  period  profound  blood  changes 
may  be  noticed.  There  is  usually  marked  anaemia  with  decrease  in  the 
number  of  red  blood-cells  and  lowered  percentage  of  hemoglobin.  The 
leucocyte  count  varies  greatly.  A  leucocytosis  of  10,000  or  over  is  not 
uncommon.  In  the  majority  of  cases  it  is  not  materially  increased, 
and  it  may  even  be  less  than  normal.  In  the  later  stages  of  the  disease 
metastatic  deposits  may  make  their  appearance  in  the  internal  organs, 
lungs,  liver,  spleen  and  even  in  the  skin.  At  this  stage,  marked  leucocy- 
tosis may  make  its  appearance.  The  constitutional  symptoms  are 
usually  not  very  characteristic.  Apart  from  the  anaemia  and  the 
symptoms  that  necessarily  accompany  it,  such  as  loss  of  strength, 
intermittent  fever  and  occasional  hemorrhages,  there  is  nothing  char- 
acteristic. The  fever,  however,  may  show  great  variations.  As  a 
rule  it  seldom  rises  over  100°  in  the  evenings,  falhng  to  normal  in  the 
mornings.  Occasionally,  however,  severe  rigors  associated  with  a 
temperature  of  102°  to  104°  may  occur  at  intervals  in  a  manner 
highly  suggestive  of  septic  absorption.  Such  chills  are  rather  rare  in 
lymphosarcoma  of  the  neck  but  are  common  in  retroperitoneal 
growths. 

The  diagnosis  in  the  very  early  stages  is  almost  impossible.  It 
rests  on  the  very  rapid  growth  and  early  infiltration  of  the  surrounding 
structures;  on  the  tendency  of  the  disease  to  impHcate  gland  after 
gland,  causing  them  to  fuse  together;  and  further  on  its  tendency,  in 
the  lower  part  of  the  neck,  to  cross  the  middle  Hne  and  implicate  the 
glands  on  the  opposite  side. 

The  prognosis  is  very  unfavorable.     There  is  grave  reason  to  believe 


344  REGIONAL   SURGERY 

that  we  have  no  authentic  record  of  a  single  recovery.  Even  after  ex- 
tensive and  complete  removal  by  operation,  death  usually  occurs 
within  a  year  from  its  first  appearance. 

Treatment. — Considering  the  uniformly  fatal  results  it  would  appear 
that  operative  procedures  should  be  condemned.  Nevertheless,  in 
cases  that  do  not  present  insuperable  anatomical  difficulties,  early  and 
complete  removal  seems  the  only  course  to  pursue.  Local  recurrences 
appear  with  unusual  rapidity;  in  fact  in  a  month  or  two  after  apparently 
complete  removal,  the  recurrence  may  be  as  large  as  the  original  growth. 
Partial  operations  are  worse  than  useless.  The  surgeon  must  be  pre- 
pared to  remove  the  carotid  artery,  jugular  vein  and  pneumogastric 
nerve  along  with  the  tumor.  It  is  needless  to  remark  that  such  exten- 
sive procedures  will  be  followed  by  a  very  high  primary  mortality.  All 
other  methods  of  treatment,  such  as  the  use  of  arsenic,  Coley's  fluid  and 
the  X-ray,  are  as  powerless  to  affect  the  growth  as  they  are  in  round- 
celled  sarcomata  growing  in  other  situations. 

Hodgkin's  Disease  {Syn.:  Malignant  Lymphoma,  Lymphadenomay 
AleukcBmic  Lymphoma) . — This  disease  is  characterized  by  a  progressive, 
painless  enlargement  of  one  or  more  groups  of  lymphatic  glands  asso- 
ciated with  progressive  ansemia  which  invariably  terminates  fatally. 
Classical  types  of  this  affection  present  a  symptom-complex  that  is  so 
characteristic  that  it  can  be  separated  sharply  from  both  lymphosar- 
coma and  lymphatic  leuksemia.  But  many  typical  cases  of  slow,  pro- 
gressive glandular  enlargement  are  met  with  which  are  attended  by 
symptoms  and  blood  pictures  that  make  a  clear  distinction  between  these 
various  affections  very  difficult  and  sometimes  impossible. 

Etiology. — The  exact  cause  is  unknown.  The  disease  is  more  com- 
mon in  men  than  in  women.  It  is  a  disease  common  to  children  and 
occurs  more  frequently  between  the  ages  of  lo  and  20  than  at  any 
other  period  of  life.  The  cervical  group  of  lymphatic  glands  being 
more  often  infected  than  the  other  glands  of  the  body  lends  some  sup- 
port to  the  theory  that  the  poison  enters  the  system  through  the  tonsils 
and  fauces.  No  uniform  bacteriological  findings  have  been  discovered. 
Experimental  inoculation  of  portions  of  glands  into  animals  have  re- 
sulted in  nothing  definite.  The  lymphatic  enlargement  which  invari-' 
ably  follows  is  transitory  and  is  a  simple  hyperplasia.  The  claims  that 
have  been  advanced  that  the  disease  is  merely  an  unusual  form  of  gen- 
eralized tuberculous  infection  is  probably  untenable. 

Pathology. — The  gross  appearance  of  the  glands  is  often  very  char- 
acteristic.    One  of  the  most  common  types  is  pictured  in  Fig.  171. 


INFLAMMATORY   AFFECTIONS    OF    THE    NECK 


345 


The  tumor  is  found  to  consist  of  a  large  number  of  glands,  the  larger 
ones  being  in  the  center.     Each  gland  is  rounded  and  discrete,  being 


of  tissue  containing 
phatics 


Fig.    ryi. — Hodgkin's  disease.     (Keiller.) 


Fig.  172. — Hodgkin's  disease.     (Kcillcr.) 


connected  with  its  neighbors  by  lymphatic  trunks  which  are  quite  con- 
spicuous.    They  are  firm  and  elastic  to  the  feel  and  on  palpation  re- 


346  REGIONAL   SURGERY 

semble  potatoes  in  a  sack.  On  section  they  are  pink  in  color  and 
firm  in  consistence.  Each  gland  is  surrounded  by  a  definite  capsule. 
The  microscopic  changes  are  usually  very  characteristic  in  the  later 
stages.  Coarse  fibrous  bands  run  from  the  capsule  into  the  tumor, 
cutting  it  up  into  lobules.     The  reticulum  is  very  thickened  and  the 


Vagus  nerve 


Groove  for  interna 
jugular  vein 


Fig.  173. — Hodgkin's  disease.     (Keiller.) 

cellular  spaces  are  extremely  narrowed.  In  the  earher  stages,  this 
tendency  to  coarsening  of  the  reticulum  is  a  marked  feature,  but  the 
cellular  spaces  are  large  and  are  filled  with  a  great  variety  of  cells,  viz. : 
lymphocytes,  epithelioid  cells,  plasma  cells,  mast  cells,  and  eosinophile 
leucocytes  (Longcope). 

In  some  instances  the  gross  appearance  of  the  glandular  enlarge- 
ments resembles  that  pictured  in  Fig.  172,  in  which  the  general  outHne 
of  the  mass  suggests  a  collection  of  separate  glands  which  have  fused 
together.  This  condition  is  occasionally  seen  in  the  neck,  and  is  very 
common  where  the  glands  are  tightly  packed  as  in  the  mediastinum. 


INFLAMMATORY   AFFECTIONS    OF    THE    NECK  347 

In  Other  instances  the  separate  glands  may  fuse  into  a  homogeneous 
rounded  or  oval  mass,  with  a  smooth  surface  surrounded  by  a  definite 
capsule,  which  does'  not  suggest  its  origin  from  a  number  of  separate 
nodes.  This  is  shown  in  Fig.  173,  which  represents  a  recurrence  in  the 
lower  part  of  the  neck  after  an  operation  for  removal  of  a  large  number 
of  discrete  glands  in  the  upper  part  of  the  neck. 

Symptoms  and  Clinical  Course. — The  first  symptom  noticed  is  the 
glandular  swelling,  which  may  appear  in  the  neck,  axilla  or  rarely  in  the 
groin  (Fig.  174).  Anaemia  and  loss  of  strength  appear  later.  The  cer- 
vical group  is  affected  most  frequently.  The  enlargement  is  slow  and 
painless  and  each  gland  is  usually  separate  from  the  others.  The  rate 
of  growth  is  usually  steady,  but  occasionally  we  meet  with  cases  in 
which  the  glands  remain  stationary  for  variable  periods.  The  rapidity 
of  growth  shows  great  variability.  In  some  cases  the  glands  grow  with 
startling  rapidity,  while  in  others  the  rate  of  growth  is  extremely  slow. 
In  many  instances  periods  of  rapid  growth  may  alternate  with  periods 
of  slow  growth.  As  a  rule,  the  extension  of  the  disease  is  in  the  direc- 
tion of  the  lymphatic  flow,  as  from  the  inguinal  to  the  iliac  and  lumbar 
glands.  As  the  glands  enlarge  they  may  produce  pressure  symptoms. 
In  the  neck  dyspnoea  from  pressure  on  the  trachea  is  the  most  distress- 
ing. Dysphagia  is  not  uncommon.  Pressure  on  the  veins  may  produce 
cyanosis  and  oedema.  (Mediastinal  and  abdominal  symptoms  are  de- 
scribed elsewhere.)  The  constitutional  symptoms  consist  of  the  follow- 
ing: fever;  progressive  anaemia;  and  the  presence  of  lymphoid  masses  in 
the  skin,  the  liver  and  spleen  producing  enlargement  of  these  organs. 
Fever  is  fairly  constant.  It  varies  in  type  but  is  usually  intermittent. 
A  relapsing  type  of  fever  has  been  noticed.  Anaemia  becomes  marked. 
The  count  of  red  blood  corpuscles  may  fall  as  low  as  2,000,000,  and  the 
percentage  of  hemoglobin  to  30  or  40.  The  white  blood  count  is  not 
characteristic.  There  is  often  a  slight  increase,  but  it  rarely  rises  higher 
than  20,000.  The  picture  never  resembles  that  of  lymphatic  leukaemia 
owing  to  the  low  percentage  of  lymphocytes.  During  the  course  of  the 
disease  both  spleen  and  liver  may  show  marked  enlargement.  Both 
these  organs  are  usually  the  seat  of  Ij-mphomatous  nodules  which  have 
been  described  as  metastatic  tumors.  As  similar  lymphomatous  no- 
dules are  occasionally  found  in  the  kidney,  lung,  pericardium  and  pleura, 
etc.,  they  are  probably  not  metastatic  tumors  but  merely  overgrowths 
of  normal  lymphoid  tissue. 

Diagnosis. — In  the  early  stages  of  the  afYection  accurate  diagnosis 
of  Hodgkin's  disease  is  usually  an  impossibility.     Without  the  aid  of  a 


348 


REGIONAL   SURGERY 


Fig.  174. — Hodgkin's  disease.     LOsler  and  McCrae.) 


INFLAMMATORY  AFFECTIONS   OF   THE   NECK  349 

microscopic  specimen  of  one  of  the  affected  glands,. it  is  impossible  to 
distinguish  it  from  lymphosarcoma,  tuberculosis  and  inflammatory 
hyperplasia.  In  the  later  stages  the  splenic  enlargement,  the  character 
of  the  glandular  enlargement,  its  slow,  indolent,  progressive  growth  and 
the  progressive  anaemia  are  usually  characteristic  of  Hodgkin's  disease. 
The  presence  of  enlarged  lymph  nodes,  in  addition  to  the  splenic  enlarge- 
ment, distinguishes  it  from  splenic  anaemia.  In  lymphatic  leukaemia  we 
usually  have  marked  glandular  enlargement  and  an  enormous  spleen. 
Blood  examinations  revealing  very  high  leucocyte  counts  (50,000  to  100,- 
000)  with  a  large  percentage  of  lymphocytes  usually  settle  any  doubts. 
In  lymphosarcomata,  the  extremely  rapid  growth  of  the  tumors  with 
their  tendency  to  infiltrate  the  surrounding  tissues  and  to  fungate 
through  the  skin  are  very  characteristic.  From  some  types  of  tuber- 
culous glandular  enlargements  the  diagnosis  is  very  difficult.  Longcope 
has  called  particular  attention  to  the  similarity  in  the  physical  signs 
between  either  one  or  two  types  of  tuberculosis  of  glands  and  Hodgkin's 
disease.  One  type,  an  acute  form  of  tuberculosis,  is  apt  to  arise  in  the 
cervical  glands.  One  or  both  sides  of  the  neck  may  be  involved,  and 
the  glands  increase  in  size  rapidly.  The  glands  are  oval,  elastic,  dis- 
crete and  painful.  There  may  be  intermittent  fever.  The  resemblance 
to  Hodgkin's  disease  may  be  perfect.  The  other  type  is  the  generalized 
caseous  variety.  Separate  groups  of  glands  in  various  parts  of  the  body 
may  be  enlarged.  Some  of  the  glands  are  discrete,  others  are  fused 
together.  Occasionally,  the  true  nature  of  the  disease  may  be  indicated 
by  a  gland  caseating  and  breaking  down  or  by  the  discovery  of  a  healed 
sinus.  There  is  often  fever  and  anaemia.  A  case  of  this  nature  was 
recently  seen  by  the  writer.  A  woman  aged  28  came  under  observation 
showing  marked  enlargement  of  the  glands  of  both  sides  of  the  neck, 
both  axillae  and  both  groins.  The  spleen  was  appreciably  enlarged. 
There  was  marked  anaemia  but  no  leucocytosis.  After  long  treatment 
by  arsenic,  with  no  improvement,  a  cervical  gland  was  removed  for 
microscopic  examination  and  proved  to  be  tuberculous.  It  is  probable 
that  many  cases  of  this  nature  have  lent  support  to  the  theory  that 
Hodgkin's  disease  is  a  tuberculous  manifestation. 

There  are  some  mahgnant  growths  which  arise  in  the  lymph  nodes 
that  have  certain  features  resembling  lymphosarcomata  and  others  re- 
sembling Hodgkin's  disease.  Paltauf  and  Sternberg  drew  distinctions 
between  sarcomata  arising  in  lymph-glands  and  lymphosarcomata. 
MacCallum  has  also  emphasized  this  point.  Longcope  has  pointed  out 
that  some  of  the  sarcomata  of  the  lymph  nodes  may  grow  more  slowly 


35©  REGIONAL   SURGERY 

than  usual  and  form  large  irregular  masses  in  the  neck  and  axilla.  The 
enlargement  may  be  painless  and  accompanied  by  fever  and  anaemia. 
Chnically  they  resemble  Hodgkin's  disease  very  closely.  Microscopic- 
ally, they  consist  of  round  cells,  often  larger  than  lymphocytes  and  of  a 
variable  amount  of  interstitial  tissue.  The  exact  position  that  these 
tumors  occupy  in  the  lymphatic  enlargements  is  hard  to  decide.  Some 
of  them  resemble  lymphosarcoma  and  others  resemble  Hodgkin's  dis- 
ease. Those  that  have  occurred  in  the  writer's  experience  have  given 
rise  to  considerable  uncertainty  as  to  their  exact  nature.  One  case  oc- 
curred in  a  boy  aged  13  years,  and  the  history  pointed  to  the  existence 
of  five  or  six  discrete  glandular  enlargements  in  the  upper  cervical 
region,  which  were  removed  six  months  before  he  came  under  my  care. 
A  diagnosis  of  Hodgkin's  disease  had  been  made.  On  examination,  a 
large  tumor  was  found  occupying  the  left  side  of  the  neck,  extending 
from  just  below  the  mastoid  process  to  the  level  of  the  sternoclavicular 
joint  where  it  projected  under  the  clavicle.  This  tumor  was  nodular, 
circumscribed  and  fairly  movable.  It  was  excised  and  with  it  segments 
of  the  internal  jugular  vein  and  sympathetic  nerve  (see  Fig.  173).  In 
the  upper  part  of  the  neck  the  removal  was  not  quite  thorough.  Ar- 
senic was  given  for  a  year  after  the  operation,  during  which  time  there 
was  no  sign  of  recurrence.  Arsenic  was  then  discontinued  and  recur- 
rence appeared  in  less  than  a  month  in  the  occipital  region.  Arsenic 
was  resumed  and  the  growth  remained  stationary  for  six  months.  It 
was  again  discontinued  and  the  growth  increased  so  rapidly  that  arsenic 
lost  control  and  the  patient  died.  Another  case  of  similar  nature  had 
an  interval  of  five  years  between  the  first  operation  for  the  removal 
of  the  sarcomatous  glands  in  the  upper  (parotid)  region  of  the  neck 
and  the  second  operation  for  the  removal  of  a  recurrence  in  the  lower 
glands  of  the  deep  cervical  chain.  After  the  second  operation,  which 
consisted  of  a  clean  removal  of  an  oval,  glandular  mass  along  with  the 
internal  jugular  vein,  two  years  of  freedom  from  recurrence  followed; 
The  second  recurrence  proved  fatal  from  infiltration  of  both  sides  of 
the  neck.  A  pathological  diagnosis  of  round-celled  sarcoma  was 
made  in  both  these  cases.  A  third  case  was  a  slowly  growing  sar- 
coma of  the  glands  of  the  left  axilla.  The  type  was  round-celled,  with 
very  large  mononucleated  cells.  There  was  an  interval  of  two  years 
between  the  first  excision  and  the  first  recurrence.  The  second  opera- 
tion was  imperfect  and  was  followed  in  a  week  by  an  interscapulo- 
thoracic  amputation.  Recurrence  of  the  growth  showed  iteslf  in  the 
scar  at  the  end  of  three  months.  This  disappeared  completely  under 
the  influence  of  the  X-ray,  before  the  patient  left  hospital. 


INFLAMMATORY   AFFECTIONS    OF   THE   NECK  35 1 

In  all  these  cases  certain  characteristics  have  stood  out  in  strong  relief : 
(i)  their  great  clinical  resemblance  to  Hodgkin's  disease  in  the  early 
stages;  (2)  the  certainty  of  recurrence  sooner  or  later  after  operation;  (3) 
their  tendency  to  become  more  maUgnant  after  each  removal;  (4)  their 
susceptibihty  to  the  therapeutic  effects  of  arsenic  and  the  X-ray. 

Prognosis. — Sooner  or  later  every  case  of  Hodgkin's  disease  has  a 
fatal  termination.  Many  cases  improve  or  remain  stationary  for  vari- 
able periods  of  time  under  suitable  treatment,  but  a  time  arrives  inevit- 
ably when  the  disease  progresses  steadily  to  a  fatal  end.  The  cause  of 
death  is  cachexia,  or  some  complication,  of  which  tuberculosis  is  by 
far  the  commonest. 

Treatment. — Although  a  permanent  cure  of  Hodgkin's  disease  has 
probably  never  been  seen,  great  improvement  will  often  result  from 
medicinal  treatment.  Arsenic  is  the  most  valuable  drug  we  can  employ 
and  it  should  be  pushed  to  the  utmost  tolerance  of  the  patient.  It  may 
be  given  by  mouth  as  Fowler's  solution,  or  hypodermically,  or  even 
intravenously  as  salvarsan.  The  immediate  effect  produced  by  X- 
rays  is  remarkable.  The  glands  shrink  and  often  disappear  entirely, 
but  reappear  as  soon  as  treatment  is  discontinued.  Operative  measures 
have  not  proved  succsesful.  Invariably,  either  a  local  recurrence  fol- 
lows or  glands  in  another  region  become  affected.  The  true  value  of 
operative  measures  has  never  been  accurately  estimated.  There  is  no 
doubt,  as  mentioned  previously,  that  partial  removal  of  the  glandular 
swelling  renders  the  portion  left  behind  more  susceptible  to  the  influence 
of  arsenic.  Therefore  it  seems  rational  to  remove  all  glands  surgically 
accessible  and  to  treat  vigorously  with  arsenic  and  X-rays  those  left 
behind.  This  practice  has  been  followed  by  the  writer  for  many  years 
with  happy  results  as  regards  prolongation  of  life. 

ADDENDUM  TO  HODGKIN'S  DISEASE 

In  igioFraenkel  and  Much  (Zeitsch.  f.  Hyg.,  i9io,LXVII,  159)  found 
present  in  the  nodes  of  Hodgkin's  disease  a  Gram-staining,  but  non-acid- 
fast,  tubercle  bacillus  or  a  bacillus  related  to  it  quite  closely.  Recently, 
Negri  and  Mieremet  (Centralblatt  fiir  bakteriol.,  1913,  LXVUI,  292) 
and  Bunting  and  Yates  (Archives of  Internat.  Medicine,  Aug.,  1913)  have 
cultivated  from  a  number  of  cases  of  Hodgkin's  disease  an  organism 
that  is  probably  identical  with  that  described  by  Fraenkel  and  Much,  and 
which  may  probably  be  proven  to  be  the  actual  cause  of  the  disease. 
The  organism  is  a  diphtheroid  bacillus,  non-acid-fast  and  Gram-stain- 
ing, which  grows    luxuriantly    at    the    body    temperature.     It    is    a 


352  REGIONAL   SURGERY 

facultative  microbe  which  shows  great  variabihty  of  form.  To  it  Negri 
and  Mieremet  have  given  the  name  of  "  Corynebacterium  granuloma- 
tosis maligni, "  while  Bunting  and  Yates  have  suggested  the  name 
"Corynebacterium  Hodgkini." 

Inoculation  experiments  on  the  monkey  {Macacus  Rhesus)  by 
Bunting  and  Yates  (Journ.  Amer.  Med.  Assn.,  Nov.  15, 1913)  have  re- 
sulted in  changes  practically  identical  with  those  found  in  the  glands  in 
Hodgkin's  disease.  Finally,  Billings  and  Rosenow  (Journ.  Amer.  Med. 
Assn.,  Dec.  13,  1913)  have  corroborated  the  observations  of  previous 
workers  and  have  treated  seven  patients  suffering  from  Hodgkin's 
disease  by  injections  of  autogenous  vaccines  prepared  from  pure  cul- 
tures of  the  organism.  In  six  of  the  patients  there  was  marked  improve- 
ment, the  lymph  nodes  decreasing  in  size  rapidly  and  uniformly.  One 
of  these  received  no  Rontgen  treatment;  two  died,  but  both  had 
marked  mediastinal  involvement.  One  patient  is  apparently  well. 
The  rest  of  the  patients  appear  to  be  improving  with  varying  degrees 
of  rapidity.  It  is,  of  coarse,  premature  to  speak  otherwise  than  in  a 
general  manner  as  to  the  true  value  of  this  method  of  treatment. 

INJURIES  OF  THE  NECK 

Injuries  of  the  neck  may  be  conveniently  divided  into  two  classes : 

1.  Contusions,  usually  produced  by  a  blow  from  a  blunt  instrument 
or  by  throttHng  or  hanging. 

2.  Open  wounds  produced  by  sharp  instruments  or  by  bullets. 

Contusions  of  the  Neck. — Apart  from  injury  to  the  hyoid  bone,  laryn- 
geal (see  elsewhere)  cartilages  and  the  trachea,  symptoms  following 
contusions  are  insignificant.  The  laceration  of  the  subcutaneous  tis- 
sues usually  affects  the  small  blood-vessels  and  the  resulting  extravasa- 
tion is  small  in  amount  and  is  rapidly  absorbed.  Rupture  of  the  large 
blood-vessels  is  so  rare  as  to  be  almost  negligible.  Where  a  contusion  is 
followed  by  marked  swelling  and  is  accompanied  by  dyspnoea,  the  symp- 
toms point  strongly  to  a  coincident  injury  of  the  box  of  the  larynx  or 
trachea,  a  condition  of  the  gravest  danger  to  the  patient  unless  relieved. 

Open  Wounds. — These  may  be  accidental  in  nature,  such  as  stabs 
or  bullet  wounds,  or  they  may  be  clean  wounds  made  by  the  surgeon 
during  operations  on  the  neck  for  the  removal  of  tumors,  etc.  In  acci- 
dental wounds  the  structures  are  sometimes  divided  in  a  cleanly  manner, 
but  where  the  instrument  is  blunt,  as  the  end  of  an  umbrella  or  in  bullet 
wounds,  severe  laceration  may  result.  It  will  facihtate  the  considera- 
tion of  this  subject  to  consider  the  wounds  of  the  important  structures 
seriatim. 


INFLAMMATORY  AFFECTIONS    OF   THE    NECK  353 

Wounds  of  Arteries. — Suicidal  wounds  of  the  large  arteries  of  the 
neck  are  comparatively  rare,  owing  to  the  fact  that  the  patient  usually 
expends  the  energy  of  the  cut  against  the  resisting  thyroid  cartilage 
which  projects  forward  and  shelters  the  large  vessels  from  injury. 
Stabs  often  result  in  a  clean  wound  and  if  the  artery  is  completely  di- 
vided the  two  ends  may  retract,  curl  up  and  become  thrombosed,  the 
bleeding  being  permanently  arrested.  If  the  wounded  artery  is  a  large 
one,  such  as  the  common  or  internal  carotid,  death  from  hemorrhage 
usually  results  promptly.  If,  however,  only  part  of  the  circumference 
of  the  artery  is  wounded  and  death  does  not  result  from  primary  hemor- 
rhage, bleeding  may  cease  when  the  blood  pressure  has  been  reduced  to 
a  low  level  from  the  loss  of  blood.  The  opening  in  the  artery  fills  with 
clot  which  may  adhere  firmly,  in  which  event  there  will  be  no  recurrence 
of  the  bleeding;  or,  the  clot  may. be  poorly  formed  and  easily  detached, 
the  result  being  a  secondary  hemorrhage;  or,  the  clot  may  be  defective 
and  incapable  of  closing  the  mouth  of  the  vessels  firmly,  a  state  almost 
invariably  followed  by  the  formation  of  an  aneurism.  Injuries  of 
arteries  by  bullets  are  not  always  followed  by  the  classical  symptoms 
of  hemorrhage.  Small  caliber,  high  velocity  bullets,  are  capable  of 
cutting  clean  punched  wounds  in  the  sides  of  arteries  which  may  be 
followed  by  immediate,  severe  and  fatal  bleeding.  A  large  proportion 
of  sudden  deaths  on  modern  battlefields  result  from  arterial  hemor- 
rhage. Low-velocity  large-caliber  bullets  may  divide  an  artery  and  the 
ends  may  be  so  contused  that  they  curl  up  and  become  thrombosed  at 
once,  practically  no  bleeding  occurring;  or,  on  the  other  hand,  they  often 
bruise  the  arterial  walls  so  severely  that  part  or  the  whole  circumference 
dies,  circulation  ceases  and  clotting  occurs.  If  the  clot  remains  aseptic, 
bleeding  will  never  be  seen,  but  if  sepsis  occurs  the  clot  may  be  detached 
and  secondary  hemorrhage  may  result. 

Symptoms  and  Diagnosis. — Hemorrhage  is,  of  course,  the  only  cer- 
tain sign  of  a  wound  of  an  artery.  In  many  instances  this  can  only  be 
ascertained  from  the  history,  bleeding  having  ceased  soon  after  the 
accident.  A  dry  wound  at  the  time  of  observation  must  not  lead  us 
to  the  conclusion  that  the  artery  is  not  wounded.  As  soon  as  the  blood 
pressure  rises,  bleeding  will  probably  recur.  If  there  is  a  history  of  a 
severe  bright-red  hemorrhage,  it  is  safer  to  assume  that  an  important 
vessel  has  been  wounded.  The  history  of  many  fatal  cases  is  clear, 
viz.,  a  severe  primary  hemorrhage  caused  by  the  injury,  followed  by  a 
number  of  recurrent  hemorrhages  at  intervals  until  the  patient  suc- 
cumbs.    In  certain  conditions,  symptoms  such  as  absence  of  pulse  in 


354  REGIONAL  SURGERY 

the  periphery  or  evidences  of  cerebral  anaemia  may  indicate  a  complete 
division  of  the  vessel.  Wahl's  sign,  i^.e.,  a  systolic  murmur  over  the  point 
of  injury,  is  not  an  absolutely  reliable  sign  of  partial  division,  of  a  vessel. 
Treatment. — If  the  case  is  seen  while  active  hemorrhage  is  present 
an  attempt  should  be  made  to  find  the  bleeding  vessel  and  close  the 
opening,  either  by  Hgature  or  by  suture.  The  patients  are  rarely  in 
surroundings  that  justify  such  courageous  surgery  and  usually  the 
wound  is  plugged  or  pressure  apphed  with  temporary  arrest  of  the 
bleeding.  The  further  conduct  of  the  case  will  depend  on  many  factors : 
(i)  length  of  time  that  has  elapsed  since  the  accident;  (2)  the  situation 
of  the  wounded  vessel;  (3)  the  condition  of  the  wound.  If  the  wound  is 
recent,  immediate  operation  should  be  contemplated  if  the  environ- 
ments are  suitable  and  the  wounded  vessel  is  accessible.  If  several 
days  have  elapsed  since  the  infliction  of  the  wound  it  is  better  to  wait 
until  infection  has  subsided.  If,  however,  the  wound  has  been  packed 
with  gauze  the  case  is  more  complicated.  Infection  is  inevitable 
sooner  or  later,  and  we  can  choose  between  the  risks  of  immediate 
hemorrhage  if  the  gauze  is  removed  at  once  and  secondary  hemorrhage 
if  the  operation  is  delayed.  The  choice  is  difficult  and  will  often  be 
decided  by  the  condition  of  the  patient,  as  to  loss  of  blood,  etc.  Wounds 
of  arteries  in  difficult  or  inaccessible  situations  must  always  be  treated 
primarily  by  expectant  methods  such  as  pressure  and  packing.  Later 
on,  if  the  condition  of  the  patient  warrants  the  procedure,  an  attempt 
may  be  made,  by  direct  attack  or  proximal  or  distal  Hgature,  to  con- 
trol the  bleeding  permanently.  From  experience  acquired  in  recent 
wars  miHtary  surgeons  have  emphasized  the  necessity  of  non-inter- 
ference with  arterial  and  arterio-venous  wounds  unless  associated  with 
open  or  concealed  active  hemorrhage.  Delay  is  advised  until  the  in- 
jured tissues  have  recovered  from  injury  and  infection.  Under  ap' 
propriate  treatment,  such  as  occlusion  of  the  wound  and  absolute  rest, 
further  bleeding  will  usually  stop  and  consolidation  of  the  wound  result. 
Of  course,  in  a  large  number  of  cases  an  aneurism  will  appear,  but  as 
time  passes  the  collateral  circulation  will  develop  and  in  a  few  months 
operation  can  be  performed  with  much  less  risk.  These  late  operations 
are  much  easier  from  an  anatomical  standpoint  because  all  the  struc- 
tures can  be  recognized  and  protected,  and  likewise  conservative  opera- 
tions can  be  practised  whereby  the  blood-vessels  can  be  saved.  Cere- 
bral anaemia  is  much  less  common  after  late  than  after  early  operations 
on  the  carotid;  while  in  wounds  of  the  peripheral  vessels  late  operations 
reduce  the  dangers  of  gangrene  to  a  minimum. 


INFLAMMATORY   AFFECTIONS    OF   THE    NECK  355 

Wounds  of  Veins. — Veins,  like  arteries,  may  be  wounded  by  stabs, 
bullets,  penetrating  foreign  bodies  and  subcutaneous  contusions.  In 
accidental  wounds,  such  as  stabs,  the  vein  and  artery  may  be  opened 
simultaneously  and  if  the  patient  recover,  one  or  other  variety  of 
arterio-venous  aneurism  may  result. 

Symptoms  and  Diagnosis. — If  the  blood  is  venous  in  character  and 
escapes  from  the  wound  in  a  regular  stream  and  not  in  intermittent 
jets,  the  wounded  vessel  is  probably  a  vein.  The  evidence  is  not  abso- 
lute, however,  especially  in  a  wound  that  has  been  inflicted  for  some 
time.  One  often  sees  blood  of  a  dark  venous  color  trickling  from  a 
wound  in  the  neck  where  operation  reveals  a  wounded  artery  only. 
Bleeding  from  injuries  of  so  large  a  vein  as  the  internal  jugular  is  so  rapid 
and  profuse  that  patients  die  very  rapidly.  If  efficient  aid  is  not  avail- 
able soon  after  the  accident,  the  mortality  is  higher  even  than  in  wounds 
of  the  large  arteries.  During  operations  on  the  neck  a  wound  of  the 
jugular  may  result  in  the  loss  of  a  prodigious  amount  of  blood  in  a  very 
short  time. 

Treatment. — The  only  rational  treatment  is  direct  closure  of  the 
wound  in  the  vein.  The  wound  in  the  neck  should  be  enlarged  and  pres- 
sure applied  on  the  bleeding  point  by  the  assistant's  finger.  The  vein 
should  be  exposed  and  the  opening  firmly  closed.  This  may  necessitate 
ligature  of  the  vein  above  and  below  the  opening.  In  other  cases  part 
of  the  wall  of  the  vein  may  be  pinched  up  and  ligatured.  In  still  other 
cases  the  opening  may  be  carefully  sutured.  Where  the  vein  is  inac- 
cessible as  in  wounds  of  the  jugular  at  the  root  of  the  neck  or  near  the 
base  of  the  skull,  we  must  rely  on  pressure  from  careful  packing.  This 
will  often  be  successful.  The  application  of  clamps  is  very  unsatis- 
factory and  must  only  be  used  as  last  resort. 

Entrance  of  Air  into  Veins. — In  the  older  writings  on  surgery,  great 
importance  was  given  to  this  accident,  which  seems  to  have  been  of 
fairly  frequent  occurrence  during  operations  for  the  removal  of  tumors. 
At  the  present  time  it  seems  to  be  rare,  owing  probably  to  smoother 
anaesthesias,  to  the  position  of  the  patient  while  operating  and  to  a 
greater  anatomical  and  technical  nicety  in  conducting  the  operations. 
It  must,  however,  be  still  considered  as  a  real  danger.  Green,  writing 
in  1864,  collected  sixty-four  cases  with  an  immediate  mortality  of 
twenty-four.  During  the  removal  of  tumors  the  accident  is  more 
likely  to  occur  when  the  tumor  has  been  separated  from  all  its  connec- 
tions except  the  deep  ones.  If  strong  traction  is  made  and  the  vein 
torn  or  opened,  air  is  sucked  into  the  vein  with  a  hissing  noise,  breathing 


^^6  REGIONAL   SURGERY 

becomes  embarrassed  and  the  patient  may  die  in  a  few  minutes.  Almost 
invariably  the  accident  happens  after  wounds  of  the  internal  jugular 
and  if  care  is  taken  early  in  the  operation  to  secure  this  vessel  and  con- 
trol or  obliterate  it  temporarily,  the  accident  can  be  prevented.  If  the 
accident  has  occurred  and  some  air  has  been  sucked  in  already,  the 
wound  should  be  flooded  immediately  with  water  to  prevent  more  air 
from  entering.  If  serious  sjrmptoms  result  from  the  air  that  has  gained 
entrance,  cardiac  stimulants  and  artificial  respiration  should  be 
employed. 

Woiinds  of  the  Thoracic  Duct. — Wounds  of  this  duct  may  be  divided 
into  two  classes:  (i)  accidental  wounds,  (2)  wounds  occurring  during 
operations  for  the  removal  of  tumors. 

Accidental  wounds  are  not  common,  and  owing  to  the  deep  position 
of  the  duct  and  its  close  relationships  with  the  internal  jugular  vein, 
the  subclavian  and  vertebral  veins,  uncomplicated  wounds  are  almost 
impossible.  Zesas  collected  twenty-four  cases,  caused  by  bullets, 
stabs,  and  fractures,  etc.  In  seventeen  of  them  chylo thorax  occurred; 
in  one,  chylous  ascites;  and  in  one,  both  complications.  One-half  of 
these  patients  died.  It  will  be  seen  from  the  above  data  that  these 
complicated  wounds  are  very  serious.  Wounds  of  the  duct  occurring 
during  the  removal  of  tumors  are  probably  fairly  common.  The 
writer  has  met  with  three  instances,  all  of  which  terminated  favorably. 
Yet  Zesas  was  able  to  collect  58  cases  only.  As  a  rule,  the  accident 
is  recognized  by  the  escape  of  chyle  as  soon  as  the  duct  is  divided. 
In  other  cases  no  flow  occurs  immediately,  but  the  wound  fills  with 
chyle  which  is  discovered  later.  The  resulting  discharge  in  some  cases 
has  been  enormous  in  quantity.  It  was  more  or  less  continuous,  but 
increased  in  quantity  during  digestion.  In  the  majority  of  cases  the 
discharge  ceased  spontaneously,  but  in  some  instances  a  permanent 
fistula  resulted.  That  the  accident  is  attended  with  some  risk  is  shown 
by  the  fact  that  five  deaths  occurred  out  of  55  collected  cases  (Fredet). 
The  cause  of  death  was  exhaustion. 

Treatment. — ^Accidental  wounds  are  best  treated  by  the  expectant 
plan,  the  complications  such  as  chylothorax  being  dealt  with  as  they 
arise.  When  the  duct  is  wounded  during  an  operation,  and  the  acci- 
dent is  recognized,  the  proximal  end  should  be  closed  with  a  ligature. 
Wounds  discovered  later  may  be  treated  either  by  tampons  or  the 
neck  may  be  reopened  and  search  made  for  the  severed  duct.  Tampon- 
ade has  not,  however,  been  followed  by  much  success.  Wherever 
feasible,  the  duct  should  be  isolated  and  carefully  ligatured.     Suture 


INFLAMMATORY   AFFECTIONS    OF    THE    NECK  357 

of  the  duct  has  been  advised.  In  one  case  Deanesley  isolated  the 
proximal  end  of  the  duct  and  implanted  it  successfully  into  the  jugular 
vein.  After  ligature  the  flow  of  chyle  usually  ceases  and  no  serious 
results  follow.  In  all  probability  the  flow  of  chyle  is  diverted  into  the 
right  thoracic  duct  which  is  often  well  developed,  or  passes  into  the 
venous  circulation  through  very  constant  anastomoses  between  the 
left  thoracic  duct  and  branches  of  the  azygos  and  left  renal  veins. 

INJURIES  TO  NERVES 

Every  nerve  in  the  neck  is  liable  to  be  injured  by  stabs  or  bullet 
wounds.  In  many  instances  large  blood-vessels  are  wounded  at  the 
same  time  and  the  nerve  lesion  is  overlooked. 

Hypoglossal  Nerve. — Except  during  the  course  of  operations  this 
nerve  is  seldom  injured.  Cases  of  division  have  been  reported  after 
stabs  and  gunshot  wounds.  The  symptoms  are  very  characteristic. 
One-half  of  the  tongue  is  completely  paralyzed.  On  inspection  the 
tongue  is  pushed  bodily  toward  the  paralyzed  side.  The  sound  edge  is 
convex  and  the  paralyzed  edge  is  straight  or  concave.  The  median 
raphe  is  concave  toward  the  paralyzed  side.  During  mastication 
the  tongue  gets  between  the  teeth.  Speech  is  thick  and  slurred.  If 
the  tongue  is  protruded  between  the  teeth,  it  points  toward  the  para- 
lyzed side.  In  the  course  of  time  hemiatrophy  of  the  tongue  will  follow 
division,  but  the  patient  regains  sufficient  control  over  the  tongue  to 
avoid  biting  it  and  learns  to  speak  clearly. 

Treatment. — If  the  accident  is  recognized  during  the  course  of  an 
operation,  the  divided  ends  of  the  nerve  should  be  sutured  together. 
Also  after  division  by  accidental  wounds  the  ends  of  the  nerve  should 
be  exposed  and  united. 

Glossopharyngeal  Nerve. — While  isolated  injuries  to  this  nerve 
must  have  occurred,  they  have  not  been  recorded.  During  extensive 
operations  the  nerve  has  been  frequently  divided.  The  symptoms 
produced  are  loss  of  sensibility  in  the  posterior  third  of  the  tongue  and 
in  the  side  of  the  pharynx,  and  difiiculty  in  swallowing  from  paralysis  of 
the  middle  constrictor  and  stylopharyngeus  muscle  (Sherren). 

The  Pneumogastric  Nerve. — The  symptoms  following  division  of 
this  nerve  during  the  course  of  an  operation  vary  within  great  limits. 
In  some  cases  serious  symptoms  come  on  immediately,  such  as  rapid 
heart  beat  and  slow  respiration.  In  others,  a  fatal  result  has  occurreil. 
In  the  course  of  an  operation,  symptoms  of  a  serious  nature  are  much 
more  likely  to  be  seen  if  the  vagus  is  irritated  by  being  dragged  on  or 


358  REGIONAL   SURGERY 

lacerated  while  trying  to  dissect  it  away  from  a  tumor,  than  if  the  nerve 
is  boldly  divided  at  once  and  sheltered  from  injury  (Pilcher) .  The 
writer  has  divided  this  nerve  six  times  during  the  course  of  operations 
and  has  never  seen  serious  results  follow.  In  two  of  the  cases  no  differ- 
ence was  noted  in  the  pulse  at  the  time  of  operation  or  during  conva- 
lescence. In  four,  the  pulse  became  sHghtly  more  rapid,  and  during 
convalescence  the  rate  of  beats  varied  from  15  to  30  more  than  normal, 
being  greatly  increased  during  excitement.  In  every  case  there  was  par- 
alysis of  the  recurrent  laryngeals.  The  high  mortaHty  of  52  per  cent, 
given  by  von  Bergmann  must  be  attributed  to  the  serious  nature  of  his 
cases  which  necessitated  removal  of  important  structures  such  as  the 
common  carotids.  It  may  be  safely  stated  that  division  of  one  vagus 
nerve  is  not  to  be  looked  upon  as  a  dangerous  procedure. 

Treatment. — If  the  accident  is  recognized,  an  attempt  should  be 
made  to  unite  the  divided  ends  of  the  nerve  to  aid  restoration  of  func- 
tion to  the  paralyzed  laryngeal  muscles.  Even  in  cases  where  no  at- 
tempt has  been  made  to  obtain  union  and  instances  where  a  consider- 
able segment  of  nerve  has  been  removed,  in  the  course  of  time  the  patient 
regains  control  of  his  voice  to  a  remarkable  extent.  A  case  under  the 
writer's  care  showed  for  years  a  mild  degree  of  tachycardia  and  hoarse- 
ness. At  the  end  of  10  years  the  voice  was  almost  normal  and  the 
tachycardia  had  disappeared.  Shelton  Horsley  has  reported  a  case  of 
secondary  suture  of  the  recurrent  larnygeal  nerve  after  division  during, 
a  goiter  operation. 

Sympathetic  Nerve. — Except  during  operations,  injuries  to  the  main 
sympathetic  trunk  alone  are  very  rare.  Most  wounds  of  the  neck  that 
are  likely  to  wound  the  sympathetic  also  wound  important  vessels  and 
other  nerves.  It  has  been  wounded  by  stabs  in  the  lower  portion  of  the 
neck.  Some  of  its  communicating  fibers  are  often  torn  in  injuries 
of  the  lower  cervical  region  of  the  spinal  cord  and  in  traction  injuries  of 
the  lower  cords  of  the  brachial  plexus  (lower  arm  type).  Division  in 
the  neck  produces  characteristic  eye  symptoriis.  The  palpebral  fissure 
is  narrowed  owing  to  a  pseudo-ptosis,  i.e.,  the  upper  lip  droops  but  is  not 
paralyzed.  There  is  enophthalmos.  The  pupil  is  usually  slightly  con- 
tracted. The  affected  side  of  the  face  is  colder  than  the  sound  side  and 
does  not  flush  or  sweat.  Absence  of  sweating  is  noticed  in  the  upper 
extremity  of  the  same  side  (Sherren).  The  heart  is  apparently  not  af- 
fected. Irritation  of  the  sympathetic  caused  by  the  pressure  of  tumors 
produces  the  opposite  of  these  symptoms,  viz.,  widening  of  the  palpebral 


INFLAMMATORY  AFFECTIONS   OF   THE   NECK  359 

fissure,  exophthalmos,  dilatation  of  the  pupils,  flushing  and  sweating  of 
the  area  of  skin  controlled  by  it.  No  serious  results  follow  removal  of  a 
segment  of  this  nerve  during  operations.  As  a  therapeutic  procedure 
the  various  sympathetic  ganglia  of  the  neck  have  been  removed  to 
cure  epilepsy  and  glaucoma  (Jonnesco). 

Spinal  Accessory  Nerve. — This  nerve  is  occasionally  wounded  acci- 
dentally. Far  more  frequently  it  is  divided  during  the  course  of  opera- 
tions for  the  removal  of  tumors.  Division  of  the  nerve  is  employed  as  a 
deliberate  procedure  for  the  relief  of  spasmodic  torticollis.  If  -divided 
in  the  anterior  triangle,  almost  complete  paralysis  of  the  sterno-mastoid 
and  paralysis  of  the  upper  portion  of  the  trapezius  result.  (The  sterno- 
mastoid  probably  receives  a  few  fibers  from  the  second  cervical  nerve, 
while  the  lower  portion  of  the  trapezius  is  well  supplied  from  the  third 
and  fourth  cervical  nerves.)  Paralysis  of  the  sterno-mastoid  does  not 
seem  to  interfere  materially  with  the  movements  of  the  neck,  although 
its  wasting  may  cause  slight  deformity.  Paralysis  of  the  upper  portion 
of  the  trapezius  is  hardly  noticeable,  except  for  a  slight-  wasting  and 
slight  drooping  of  the  shoulder.  If,  however,  as  may  easily  occur  in 
extensive  operations  on  the  lymphatic  glands,  both  spinal  accessory 
and  the  branches  of  the  third  and  fourth  cervical  are  divided,  marked 
deformity  results.  The  trapezius  shrinks  and  the  neck  wastes,  the 
shoulder  droops  markedly,  and  the  scapula  rotates  forward.  Viewed 
from  behind,  the  vertebral  border  and  lower  angle  of  the  scapula  are 
more  prominent  (winged  scapula).  The  movements  of  the  arm  are 
seriously  interfered  with.  When  abducted  outward  at  right  angles  to 
the  body  the  arm  cannot  be  raised  above  the  head  (Sherren). 

Treatment. — The  greatest  care  should  be  taken  during  operations 
to  preserve  the  spinal  accessory  from  injury.  If  division  is  unavoid- 
able, the  divided  ends  should  be  sutured. 

Cervical  Plexus. — Injuries  to  branches  of  this  plexus  are  more  com- 
mon during  extensive  operations  than  as  the  result  of  accidental  wounds. 
While  removing  large  glandular  tumors  from  the  posterior  triangle,  they 
are  often  unavoidably  wounded.  As  the  most  vulnerable  nerves  are 
sensory  branches,  very  little  harm  is  done,  at  least  permanently,  for 
the  anaesthesia  that  follows  their  division  soon  disappears.  The  sen- 
sory nerves  derived  from  the  cervical  plexus  may  be  divided  into  two 
sets,  an  ascending  and  descending  set.  The  ascending  branches  arise 
from  the  loop  between  the  second  and  third  nerves  and  are  respectively 
the  transverse  cervical,  the  great  auricular  and  the  small  occipital. 


36o 


REGIONAL   SURGERY 


They  arise  in  a  bunch  and  diverge  to  their  destinations  from  a  point 
on  the  posterior  edge  of  the  sterno-mastoid  near  its  middle.  Here  they 
can  be  exposed  and  cocainized.     The  descending  set  arise  from  the  loop 


between  the  third  and  fourth  nerves  and  pass  downward  over  the  ster- 
num (sternal),  clavicle  (clavicular)  and  acromion  (acromial).  As  these 
nerves  probably  assist  the  facial  nerves  in  the  supply  of  the  platysma  and 


INFLAMMATORY   AFFECTIONS    OF   THE   NECK  36 1 

arise  from  the  same  roots  that  supply  the  trapezius,  they  supply  the  skin 
area  over  the  whole  extent  of  these  muscles.  Fig.  175  borrowed  from 
Sherren  illustrates  clearly  the  area  of  anaesthesia  and  is  a  beautiful 
illustration  of  Hilton's  law. 

Phrenic  Nerve. — This  nerve  arises  mainly  from  the  anterior  branch 
of  the  fourth  cervical  nerve,  and  receives  fairly  constant  accessory 
branches  from  the  third  and  fifth.  The  main  trunk  lies  on  the  anterior 
surface  of  the  scalenus-anticus  muscle  to  which  it  is  closely  applied  in 
the  whole  of  its  course  down  the  neck.  Accidental  wounds  of  this  nerve 
are  very  rare.  During  operations,  especially  for  the  removal  of  tumors 
from  or  ligature  of  arteries  in  the  lower  part  of  the  neck,  the  nerve  is  in 
some  danger,  but  owing  to  its  intimate  relation  with  the  scalenus-anti- 
cus and  its  comparative  remoteness  from  the  lymphatic  glands  it  usu- 
ally escapes  damage.  It  is  the  experience  of  the  writer  that  it  is  one  of 
the  structures  most  easily  avoided  in  the  surgery  of  the  lower  neck. 
Schroeder  and  Green  in  1902  reported  a  case  of  division  of  the  phrenic 
while  removing  a  fibroma  of  the  neck.  The  nerve  ends  were  sutured  im- 
mediately. The  respirations  increased  in  frequency  (32  per  minute) 
and  remained  frequent  for  a  few  days.  The  patient  had  no  difficulty 
in  breathing  and  recovered  without  further  symptoms.  They  reported 
five  other  cases  all  of  which  were  fatal.  It  is  probable  that  the  cases 
reported"  up  to  this  time  were  notun  complicated,  but  that  other  vital 
structures  had  been  injured.  There  seems  to  be  no  reason,  either  from 
an  anatomical  or  physiological  standpoint,  why  any  serious  results 
should  follow  the  division  of  one  phrenic  nerve.  Paralysis  of  one-half  of 
the  diaphragm  follows,  but  the  intercostal  muscles  are  fully  capable  of 
carrying  on  respiration  on  the  affected  side.  Pulmonary  trouble  may 
occur.  In  one  case  reported  by  Erichsen  and  Riedel,  death  occurred  from 
pneumonia. 

Treatment. — Immediate  suture  should  be  employed  in  all  cases  of 
division  of  this  nerve  during  an  operation.  In  cases  of  accidental  in- 
jury the  operation  may  be  undertaken  in  uncompHcated  cases. 

Injuries  of  the  Brachial  Plexus. — The  brachial  plexus  is  formed  by 
the  union  of  the  anterior  primary  divisions  of  the  fifth,  sixth,  seventh 
and  eighth  cervical  nerves  and  the  first  dorsal  nerve  (Fig.  176).  Before 
union  these  nerves  can  be  seen  as  separate  trunks  lying  between  the 
scalenus-anticus  and  scalenus-medius  muscles.  In  subjects  with  very 
sloping  shoulders  and  correspondingly  low  clavicles,  all  the  roots  may  lie 
in  the  neck  above  the  level  of  the  clavicle.  In  an  average  person  the 
lowest  two  cords  are  usually  below  this  level.     Stabs  above  the  clavicle 


362 


REGIONAL   SURGERY 


may  wound  any  of  the  roots.  Wounds  of  the  eighth  cervical  and  first 
dorsal  roots  are  usually  attended  with  serious  injury  to  the  third  part 
of  the  subclavian  artery,  which  lies  in  front  of  them.  We  possess  at 
the  present  time  a  fairly  accurate  knowledge  of  the  distribution  of 
the  motor  roots  which  has  been  acquired  from  the  study  of  clinical 
cases  after  nerve  division  and  from  stimulation  of  the  roots  during 


JttntiUu  s  (D?aphragnia) 


>/*«  *t  ut/rtLSfit/uiiiU 
Cora£0  hrachijoL's 
"  QBiceps 


Lcty  exCaserS'^  fit  fa* 


Fig.  176. — Semidiagrammatic  scheme  to  show  the  formation  of  the  brachial  plexus  and  the 
nerve-supply  to  the  muscles  of  the  upper  extremity.     {Kocher,  Keen's  Surg.) 


operative  procedures;  but  our  knowledge  of  the  sensory  distribution  of 
these  roots  is  very  imperfect. 

The  sensory  distribution  seems  to  vary  within  great  limits,  owing 
mainly  to  the  overlapping  of  the  sensory  fibers  from  contiguous  roots. 
Apart  from  the  apparent  irregularity  caused  by  imperfect  methods 
of  testing  between  protopathic  and  epicritic  sensibility  there  is  a  real 
irregularity  due  to  the  overlapping,  varying  in  extent  in  different 
individuals.  Thus  there  is  the  greatest  divergence  of  symptoms.  In 
one  individual  division  of,  say  the  fifth  and  sixth  roots,  may  be  unat- 
tended by  any  sensory  symptoms,  whereas  in  another,  areas  of  anaesthesia 
are  found.  The  appearance  or  absence  of  anaesthesia  after  division 
depends  entirely  on  the  degree  of  overlap  of  the  sensory  fibers  in  the 
adjacent  roots.  In  cases  where  definite  areas  of  loss  of  sensibility 
appear,  their  extent  seems  to  correspond  with  the  full  protopathic 
supply  of  the  severed  nerves.  Division  of  the  posterior  roots  of  the 
spinal  nerves  also  cuts  off  the  nerves  presiding  over  protopathic  sen- 
sibihty  and  we  find  that  the  area  of  loss  of  protopathic  sensibility  is 
larger  than  that  of  epicritic.  We  also  find  in  the  cervical  and  to  a  less 
extent  in  the  other  regions  of  the  cord  great  overlapping  of  the  areas 
of  sensory  supply.  As  a  rule,  division  of  three  successive  roots  will 
produce  some  area  of  anaesthesia  but  in  some  cases  a  greater  number 


INFLAMMATORY  AFFECTIONS   OF   THE   NECK  363 

can  be  divided  without  sensation  or  the  reflexes  being  affected.  Binnie 
quotes  Taylor  as  having  "in  one  case  divided  six  successive  roots  from 
the  twelfth  dorsal  to  the  fifth  lumbar  inclusive,  on  one  side,  with  full 
retention  of  sensation." 

The  motor  distribution  of  the  upper  and  lower  roots  has  been  fairly 
accurately  worked  out,  but  that  of  the  middle  roots  less  accurately, 
owing  to  the  comparative  infrequency  of  injuries  of  the  latter.  The 
following  table,  taken  from  Sherren,  which  differs  in  a  few  unimportant 
particulars  from  those  of  Thorburn  and  others,  is  a  resume  of  our 
present  knowledge  of  this  distribution  to  the  muscles  of  the  upper 
extremity. 

Fifth  Cervical. — Deltoid,  biceps,  brachialis,  anticus,  supinators, 
rhomboids,  usually  the  spinati,  occasionally  the  radial  extensors  of  the 
wrist,  rarely  the  pronator  radii  teres. 

Sixth  Cervical. — Pronators,  radial  extensors  of  the  wrist,  clavicular 
portion  of  pectoralis  major,  serratus  magnus. 

Seventh  Cervical. — Triceps,  extensor  carpi  ulnaris,  extensors  of  the 
fingers,  pectoraHs  major. 

Eighth  Cervical. — Flexors  of  the  wrist,  flexors  of  the  fingers. 

First  Dorsal. — Intrinsic  muscles  of  the  hand. 

Damage  may  be  inflicted  on  the  brachial  plexus  and  its  component 
parts  in  one  of  two  ways: 

1.  The  injury  may  be  isolated,  i.e.,  it  may  be  inflicted  by  a  pointed 
instrument,  such  as  a  knife  or  by  a  bullet,  and  produce  a  locahzed  in- 
jury such  as  contusion  or  division  of  a  root  entering  the  plexus  or  some 
component  part  of  the  plexus. 

2.  The  injury  may  be  more  diffuse,  i.e.,  it  may  be  produced  by  trac- 
tion on  the  nerves  caused  by  a  direct  pull  on  the  arm  when  the  neck  is 
fixed,  or  a  pull  on  the  neck  when  the  arm  is  fixed. 

Isolated  injuries  may  sever  one  or  two  cords  and  produce  definite 
types  of  paralysis.  The  writer  has  seen  a  typical  Erb-Duchenne  paraly- 
sis result  from  division  of  the  fifth  cervical  root  from  a  bullet;  and  also 
the  lower-arm  type  of  paralysis  result  from  a  stab  which  severed  the  root 
of  the  first  dorsal  nerve. 

In  bullet  wounds  the  conductivity  of  the  nerve  is  often  permanently 
destroyed  even  when  the  trunk  is  merely  contused  and  not  divided. 
In  a  large  number  of  cases  of  mere  contusion  motor  power  is  regained 
to  a  certain  degree  with  the  lapse  of  time.  The  diagnosis  between 
contusion  followed  by  temporary  loss  of  conductivity  only  and  complete 
destruction  of  the  conducting  fibers  can  only  be  arrived  at  after  the  lapse 


364  REGIONAL   SURGERY 

of  a  week  or  two.  The  paralyzed  muscles  should  be  tested  frequently 
at  intervals  of  a  few  days  for  the  reaction  of  degeneration.  If  this  ap- 
pears, which  it  may  do  as  early  as  the  end  of  the  second  or  third  week, 
it  is  evidence  of  complete  destruction  of  the  conducting  fibers  and  opera- 
tion should  not  be  delayed.  If,  however,  the  reaction  of  degeneration 
does  not  appear,  the  chances  are  that  regeneration  will  result  in  time 
and  that  the  return  of  function  in  the  paralyzed  muscles  will  be  assured, 
to  a  fair  extent  at  least. 

In  a  case  under  the  care  of  the  writer,  the  patient  had  been  shot  in 
the  neck  four  months  previously.  Paralysis  of  the  shoulder  followed 
immediately.  There  had  been  slight  gradual  improvement  in  the  use 
of  the  shoulder  since  the  accident.  There  was  no  anaesthesia.  The 
deltoid,  biceps,  supinators  and  brachialis  anticus  were  paralyzed  and 
wasted.  There  was  sluggish  response  to  both  the  faradic  and  galvanic 
currents  but  no  reaction  of  degeneration.  Operation  revealed  complete 
division  of  the  fifth  cervical  nerve  root  just  at  its  junction  with  the 
sixth,  also  evidences  of  destruction  of  part  of  the  sixth  root.  The  scar 
tissue  was  removed  and  the  proximal  end  of  the  fifth  root  sutured  into 
a  slit  made  into  the  upper  side  of  the  junction  of  the  fifth  and  sixth  roots. 
The  patient  remained  under  our  care  for  six  weeks  and  during  that 
time  did  not  show  any  improvement. 

In  another  case  of  division  of  the  root  of  the  first  dorsal  nerve  by  a 
stab,  there  was  complete  motor  paralysis  of  all  the  intrinsic  muscles  of 
the  hand,  which  was  followed  by  degeneration  but  no  loss  of  sensation. 
The  patient  had  complete  control  of  all  the  flexor  and  extensor  muscles 
of  both  wrist  and  fingers.  In  two  other  cases  of  bullet  wound  which 
passed  through  the  brachial  plexus  just  below  the  clavicle,  the  patient 
recovered  complete  use  of  all  the  muscles  of  the  arm  and  forearm  ex- 
cept those  supplied  by  the  musculo-spiral  nerve.  In  neither  of  these 
cases  was  there  any  permanent  ansesthesia.  A  temporary  numbness 
followed  the  accident  but  sensation  was  soon  restored. 

Diffuse  Injuries. — These  may  be  produced  by  traction  on  the  arm 
either  at  birth  or  during  adult  Hfe.  The  mechanism  of  the  injury  is  the 
same  in  each  case,  and  consists  in  overstretching,  to  the  point  of  rupture, 
of  the  roots  entering  into  the  brachial  plexus.  If  the  injury  is  sustained 
by  the  roots  of  the  fifth  and  sixth  cervical  nerves  the  upper-arm  type  or 
Erb-Duchenne  paralysis  results.  If  the  lower  roots  are  affected,  the 
"lower-arm  type"  or  Klumpke  paralysis  results.  Forcible  traction 
of  the  arm  downward  will  produce  the  former  and  forcible  traction  up- 
ward, the  latter.     The  middle  roots,  i.e.,  the  seventh  and  eighth  cervical. 


INFLAMMATORY   AFFECTIONS    OF   THE   NECK  365 

invariably  escape  injury  in  all  cases,  except  those  of  complete  rupture 
of  all  the  cords  of  the  plexus.  Paralysis  of  both  these  types  has  been 
met  with  as  a  post-anaesthetic  complication,  resulting  from  undue  trac- 
tion or  pressure  on  the  nerves  caused  by  a  vicious  position  on  the  oper- 
ating table.  Crutches  applied  over  the  shoulder  during  prolonged  op- 
erations in  the  Trendelenburg  position  may  cause  the  upper-arm  type  of 
paralysis,  and  strong  traction  of  the  arm  upward  above  the  head  may 
cause  the  lower-arm  type.  Other  rarer  causes  may  be  looked  for  in  the 
following  conditions:  From  the  direct  pressure  of  the  head  of  a  dislo- 
cated humerus  or  from  attempts  to  reduce  such  a  dislocation  by  traction 
with  the  heel  in  the  axilla;  from  fractures  of  the  upper  end  of  the  hu- 
merus or  the  neck  of  the  scapula;  as  a  very  rare  complication  of  fractures 
of  the  clavicle;  and  from  the  pressure  of  a  cervical  rib.  A  complete 
description  of  the  symptoms  attending  the  upper-  and  lower-arm  types 
will  be  found  in  the  article  on  birth  palsy. 

Lesions  of  the  Whole  Plexus. — These  injuries  are  of  rare  occurrence. 
Complete  avulsion  causes  total  motor  paralysis  of  all  the  muscles  of  the 
arm  and  forearm  supplied  by  the  plexus,  followed  by  a  rapid  loss  in 
faradic  irritability  and  a  quick  appearance  of  the  reaction  of  degenera- 
tion. The  area  of  anaesthesia  has  been  carefully  studied  by  Sherren 
who  has  corrected  the  erroneous  impressions  of  others  as  to  the  signifi- 
cance of  the  areas  of  normal  sensation  in  the  upper  arm.  Figs.  177 
and  178  taken  from  Sherren  show  clearly  the  areas  of  anaesthesia  and 
normal  sensation.  The  boundary  is  marked  clearly  by  a  black  line. 
Distal  to  the  boundary  we  have  a  narrow  zone  (shown  by  crosses) 
where  epicritic  sensation  is  lost,  but  where  protopathic  sensation  is  still 
present.  Distal  to  this  zone  we  have  an  area  which  occupies  the  whole 
upper  extremity  where  both  protopathic  and  epicritic  sensibility  are 
lost.  The  area  of  normal  sensation  on  the  point  of  the  shoulder  and 
over  the  upper  part  of  the  deltoid  muscle  corresponds  to  the  distribu- 
tion of  the  acromial  nerves  derrived  from  the  descending  branches  of 
the  cervical  plexus.  That  on  the  inner  and  posterior  aspect  of  the  arm 
corresponds  to  the  distribution  of  the  intercostohumeral  nerve  (Figs. 
179  and  180).  The  sympathetic  fibers  which  run  in  the  trunk  of  the 
first  dorsal  nerve  root  are  also  torn,  and  we  find  the  pupil  on  the  aft'ected 
side  strongly  contracted.  It  does  not  dilate  when  shaded  from  the 
light,  but  reacts  to  cocaine.  In  some  cases  we  find  the  palpebral  fissure 
narrowed. 

The  prognosis  of  such  injuries  is  very  unfavorable.  Complete 
paralysis  and  atrophy  of  the  muscle  of  the  arm  and  forearm  are  inevit- 


366 


REGIONAL   SURGERY 


able  unless  the  torn  nerves  are  united.  Delay  in  the  operation  is  in- 
advisable because  the  distal  nerve  cords  retract  considerably  and  their 
individual  elements  become  unrecognizable  in  a  mass  of  scar  tissue  after 
the  lapse  of  a  few  weeks.  Bolton  reported  two  cases  operated  on,  one 
at  the  end  of  five  weeks  where  the  nerve  cords  were  embedded  in  a  mass 


of  recent  granulation  tissue,  the  other  at  the  end  of  nine  months  where 
the  separate  elements  were  embedded  in  a  mass  of  dense  scar  tissue. 
In  neither  of  these  cases  was  it  possible  to  unravel  the  separate  cords  or 
to  bring  the  distal  and  proximal  ends  of  the  severed  nerves  together,  and 
the  attempt  at  suture  was  abandoned.     Bristow  reported  a  case  of 


INFLAMMATORY   AFFECTIONS    OF   THE   NECK 


367 


368 


REGIONAL   SURGERY 


immediate  suture  of  all  the  cords.  At  the  end  of  a  month  the  reaction 
of  degeneration  was  noticed  in  the  deltoid,  biceps  and  triceps,  and  there 
was  no  electrical  response  whatever  in  the  extensor  and  flexor  groups 
of  the  wrist  and  fingers.     He  thought  sensation  had  improved  over  the 


Fig.  179. — Cutaneous  nerves  of  the  up- 
per limb.  Dorsal  aspect.  {W.  Keiller, 
Keen's  Surg.) 


Fig.  180. — Cutaneous  nerves  of  the  up- 
per limb.  Ventral  aspect.  {W.  Keiller, 
Keen's  Surg.) 


region  of  the  internal  cutaneous  nerve.  Later  reports  as  to  the  condi- 
tion of  such  cases  as  the  one  reported  are  needed  before  an  accurate 
estimate  can  be  formed  as  to  the  efficacy  of  immediate  suture. 

INJURIES  OF  SPECIAL  ARTERIES 

The  Carotid  Artery  and  Its  Branches. — Wounds  of  the  common 
carotid  are  more  frequent  than  those  of  the  internal  carotid.  Those 
affecting  the  various  branches  of  the  external  carotid  are  fairly  common 
but  are  rarely  attended  with  serious  danger  to  Hfe,  owing  to  their 
comparatively  small  size,  easy  accessibihty  and  peripheral  distribution. 
In  wounds  of  the  common  and  internal  carotid  the  primary  hemorrhage 
is  often  fatal  before  assistance  is  available.     In  cases  that  survive  the 


INFLAMMATORY  AFFECTIONS   OF   THE  NECK  369 

primary  hemorrhage,  the  risks  of  recurrent  and  secondary  hemorrhage 
are  unusually  great  unless  the  wounded  vessel  is  promptly  tied.  Even 
if  these  risks  are  safely  passed,  traumatic  aneurisms  make  their  appear- 
ance in  a  large  proportion  of  cases.  The  accident  must  always  be  looked 
upon  as  one  of  the  gravest  in  surgery,  because  Ugature  of  the  carotid 
for  any  reason  is  always  a  dangerous  operation  in  middle-aged  and  old 
people  owing  to  the  collateral  circulation  being  defective  in  the  circle 
of  Willis.  The  dangers  are  greatly  increased  in  the  presence  of  profound 
anaemia  and  sepsis.  Even  in  comparatively  young  people  with  good 
arteries,  death  may  follow  rapidly  on  the  heels  of  a  complete  oblitera- 
tion of  the  common  carotid.  The  writer  has  seen  death  occur  from 
cerebral  anaemia  five  minutes  after  ligature  of  the  common  carotid  for  a 
wound  inflicted  three  days  previously.  The  patient,  a  woman  of  33 
years  of  age,  had  suffered  from  a  very  severe  hemorrhage  at  the  time 
of  the  accident,  but  there  had  been  no  subsequent  bleeding.  Her 
condition  at  the  time  of  operation  was  very  fair.  The  right  common 
carotid  was  ligatured  above  and  below  a  wound  that  severed  three- 
quarters  of  the  circumference  of  the  vessel.  The  patient's  pulse  and 
respiration  became  very  rapid,  unilateral  right-sided  convulsions  made 
their  appearance  and  death  followed  in  a  few  minutes.  In  two  other 
instances  of  stab  wounds  of  the  common  carotid  treated  by  the  ex- 
pectant method,  secondary  hemorrhage  resulted.  In  each  case  bleed- 
ing was  stopped  by  a  ligature  placed  above  and  below  the  wound,  but 
was  followed  by  coma  which  proved  fatal  within  24  hours. 

Symptoms  and  Diagnosis. — Usually  there  is  only  one  symptom, 
namely,  sudden  profuse  bleeding  of  the  arterial  type.  If  the  case  is 
seen  at  once,  the  diagnosis  is  easily  made,  but  if  some  time  has  elapsed 
since  the  accident  we  may  have  to  rely  on  the  history.  Extreme  anaemia 
may  be  corroborative  of  the  amount  of  blood  lost,  and  symptoms  of 
cerebral  anaemia  or  absence  of  pulse  in  the  peripheral  arteries  may  sug- 
gest complete  division.  As  previously  stated.  Von  Wahl's  sign,  i.e.,  a 
systolic  murmur  over  the  wounded  artery,  is  not  absolutely  reliable  as  a 
symptom  of  partial  division. 

Treatment. — The  general  principles  underlying  rational  treatment 
have  been  outlined  before.  In  mihtary  practice  it  is  neither  convenient 
nor  wise  to  attempt  to  Ugature  the  bleeding  vessel  until  the  patient  is 
removed  to  one  of  the  base  hospitals.  The  mortality  of  operations  con- 
ducted on  the  field  has  been  unusually  high.  A  temporary  dressing 
should  be  applied  to  occlude  the  wound  and  prevent  external  bleeding. 
In  time,  internal  bleeding  will  cease  in  the  majority  of  cases  after  the 


37©  REGIONAL   SURGERY 

formation  of  a  large  hematoma,  which  is  often  the  forerunner  of  a 
traumatic  aneurism.  When  a  traumatic  aneurism  has  formed,  the 
case  can  be  treated  at  leisure.  Operations  performed  at  such  a  late  date 
are  attended  by  a  very  low  mortality.  But,  on  the  other  hand,  if  the 
hematoma  remains  diffused  and  shows  a  tendency  to  increase  in  size, 
early  operation  becomes  imperative;  but  even  at  this  comparatively 
early  period  the  loss  of  blood  has  been  restored  to  such  an  extent  that 
the  prognosis  is  almost  always  more  favorable  than  it  would  be  if  opera- 
tion were  undertaken  immediately  after  the  injury.  In  civil  practice 
an  immediate  operation  to  secure  the  bleeding  point  is  permissible  if 
the  patient's  condition  is  satisfactory  and  the  case  is  undertaken  by  an 
expert  surgeon  in  the  best  of  surroundings.  Where  these  conditions  do 
not  exist,  it  is  wiser  to  wait  until  a  traumatic  aneurism  has  formed  if 
the  progress  of  the  case  justifies  such  a  course.  If  an  occlusive  dressing 
is  appKed  and  a  careful  watch  kept  on  the  neck,  any  further  bleeding 
will  form  a  hematoma.  If  this  shows  any  tendency  to  increase  pro- 
gressively, the  wound  must  be  opened  and  an  attempt  made  to  secure 
the  wounded  artery  at  any  cost.  But  if  the  hematoma,  after  reaching  a 
certain  size,  remains  stationary,  an  aneurism  will  probably  form  and 
this  can  be  treated  at  leisure.  During  the  first  two  weeks  we  can  only 
make  a  shrewd  guess  at  the  probable  fate  of  the  case,  and  if  a  decision 
has  been  made  to  treat  it  on  the  expectant  plan,  we  must  be  ready  to 
meet  emergencies  quickly  as  they  arise.  Recurrent  hemorrhage  may 
appear  as  soon  as  the  lowered  blood  pressure  rises  and,  if  repeated  from 
time  to  time,  may  prove  fatal.  If  an  occlusive  dressing  has  been  ap- 
plied, these  hemorrhages  may  increase  the  size  of  the  hematoma,  the 
extravasated  blood  burrowing  along  the  planes  of  the  neck  and  produc- 
ing very  serious  pressure  symptoms.  Secondary  hemorrhage  may  ap- 
pear, usually  after  the  sixth  day.  This  is  of  the  gravest  import.  Often 
sudden  and  overwhelming,  it  may  kill  the  patient  in  a  few  minutes;  or 
it  may  show  itself  as  a  constant  dribble  which  gradually  saps  his  strength. 
In  whatever  form  it  appears,  the  treatment  must  be  prompt  and  vig- 
orous. If  feasible  and  the  patient's  condition  justifies  it,  the  wound 
should  be  opened  and  the  artery  ligatured  above  and  below  the  bleeding 
point.  There  is  probably  no  operation  more  difficult  to  complete,  be- 
cause the  wound  is  infected,  the  tissues  are  friable  and  the  arteries 
are  soft  and  often  incapable  of  holding  a  hgature;  and  when,  in  addition, 
the  wound  is  obscured  by  constant  bleeding,  ligature  of  the  artery  may 
be  impossible.  Under  such  circumstances  the  only  alternative  is  to 
pack  the  wound  with  antiseptic  gauze,  which  in  rare  instances  may  stop 


INFLAMMATORY   AFFECTIONS    OF   THE   NECK  37 1 

the  bleeding  permanently,  but  which  as  a  rule  only  gives  a  brief  respite. 
Sooner  or  later  bleeding  reappears  and  finally  kills  the  patient. 

Subclavian  Artery. — Wounds  of  the  subclavian  artery  may  be  caused 
by  stabs  or  bullet  wounds.  Compared  with  wounds  of  the  carotid 
artery  they  are  uncommon.  Wounds  of  the  first  part  of  the  artery 
are  liable  to  be  complicated  by  wounds  of  the  subclavian  vein  near 
its  confluence  with  the  internal  jugular.  Also  the  apex  of  the  lung  is 
in  danger.  Wounds  of  the  third  part  of  the  artery  are  often  associated 
with  injury  to  some  of  the  cords  of  the  brachial  plexus.  The  prognosis 
of  such  injuries  is  very  unfavorable.  Most  cases  die  promptly  of  pri- 
mary hemorrhage.  Secondary  hemorrhage  is  not  uncommon  and  is 
usually  fatal.  Hemothorax  and  pulmonary  complications  are  an  added 
danger.  In  cases  that  escape  these  complications,  aneurisms  usually 
develop  in  the  course  of  time. 

Treatment. — The  remarks  that  have  been  made  concerning  the  treat- 
ment of  wounds  of  the  carotid  are  relevant  here  also.  Immediate 
operation  is  often  the  safest  course,  and,  where  the  patient's  condition 
admits  and  the  artery  is  accessible,  should  be  attempted.  If  the  cases 
are  seen  after  primary  hemorrhage  has  ceased,  perhaps  the  wisest 
course  to  pursue  is  to  apply  an  occlusive  dressing  and  place  the  patient 
under  close  observation,  making  preparations  to  close  the  wounded 
artery  if  bleeding  occurs.  If  a  circumscribed  hematoma  forms,  a  trau- 
matic aneurism  will  probably  result,  which  can  be  operated  upon  later 
without  any  great  danger  to  the  patient's  life. 

Vertebral  Artery. — Wounds  of  the  vertebral  artery  are  very  rare. 
The  artery  may  be  wounded  at  any  point  in  the  neck,  either  before  it 
enters  the  foramen  in  the  transverse  process  of  the  sixth  cervical  verte- 
bra, or  between  the  vertebrae,  or  as  it  winds  round  the  arch  of  the  atlas. 
The  artery  is  most  frequently  wounded  in  the  last  situation.  Owing 
to  the  inaccessibility  of  the  artery  the  accident  is  a  very  serious  one. 
In  wounds  of  the  lower  portion  of  the  neck,  a  severe  external  hemorrhage 
may  result  or  a  large  hematoma  may  form  in  the  deeper  cervical  planes. 
Wounds  higher  up  may  be  complicated  by  injury  to  the  spinal  cord. 

Treatment. — If  the  patient's  condition  justifies  it,  an  attempt  should 
be  made  to  ligature  the  wounded  vessel.  Failing  to  reach  the  bleeding 
point,  the  wound  should  be  packed  firmly  with  gauze.  Wounds  of  the 
artery  above  the  sixth  transverse  process  may  be  treated  by  ligature 
of  the  vertebral  trunk  before  it  enters  the  foramen.  This  procedure 
might  stop  the  bleeding  or  check  it  sufficiently  to  enable  the  operator 
to  Hgature  the  bleeding  point. 


372  REGIONAL   SURGERY, 

DISEASES  OF  THE  BLOOD-VESSELS 

A.  Acute  arteritis. 

The  arteries  of  the  neck  are  subject  to  the  same  inflammatory  proc- 
esses that  attack  the  arteries  of  the  rest  of  the  body.  A  very  brief 
description  will  suffice.  Matas  has  divided  the  acute  processes  into 
three  main  groups  as  follows: 

1 .  Pyogenic  or  Suppurative  Arteritis. — This  occurs  typically  where 
an  arter}^  is  directly  in  contact  with  virulent  pus,  as  in  acute  abscesses. 
These  are  of  course  very  common  in  the  neck,  following  such  affections 
as  tonsillitis,  alveolar  abscesses,  etc.  In  certain  conditions  of  lowered 
resistance  of  the  tissues  and  unusual  virulence  of  the  infection,  the 
arterial  wall  sloughs  like  the  cellular  tissue.  It  is  probable  that  gan- 
grene of  the  walls  of  arteries  would  occur  more  frequently  if  it  were  not 
that  they  are  nourished  by  their  own  vasa  vasorum.  The  organisms 
usually  found  in  these  abscesses  are  staphylococci  or  streptococci  or 
both.  The  results  are  often  disastrous.  While  thrombosis  may  result 
and  the  arterial  walls  become  occluded,  as  a  rule  the  clot  is  defective 
and  is  easily  forced  out  by  the  blood  pressure  behind  it.  Secondary 
hemorrhages  are  the  rule  and  often  prove  fatal.  Occasionally  after  an 
acute  abscess  has  been  opened,  a  smart  hemorrhage  occurs  and  this  may 
be  followed  by  others  until  the  patient's  vitality  is  exhausted. 

2.  Localized  Septic  Endarteritis  of  Embolic  {PycBmic)  Origin. — 
This  condition  is  the  result  of  infected  emboli  which  have  lodged  in  the 
affected  artery.  The  original  source  of  the  embolism  may  have  been 
the  valves  of  the  heart  or  an  infected  thrombus  of  a  more  proximal 
artery.  The  immediate  result  of  such  an  embolus  is  the  blocking  of 
the  vessel  and  interference  with  the  peripheral  circulation,  which  may 
possibly  result  in  gangrene.  Locally,  the  inflammatory  changes  that 
occur  around  the  infected  embolism  may  result  in  widespread  throm- 
bosis, which  may  quickly  break  down  into  an  abscess  or  later,  result 
in  the  formation  of  an  aneurism. 

3.  Acute  Non-pyogenic  Arteritis. — The  causes  of  this  condition  are 
usually  toxasmic  and  are  caused  by  non-pyogenic  bacterial  infections. 
They  are  rarely  caused  by  traumatisms.  The  processes  are  often  seen 
following  such  diseases  as  typhoid  and  the  exanthemata.  The  struc- 
tural changes  that  occur  in  the  arterial  wall  do  not  lead  to  progressive 
ulceration  or  purulent  infiltration.  The  arteries  most  commonly  af- 
fected are  those  of  the  lower  extermity.  The  intima  of  the  vessels  suf- 
fers mainly.  The  process  is  one  of  inflammation  of  the  coats  of  the 
intima  associated  with  great  infiltration  of  leucocytes  ending  in  marked 


INFLAMMATORY   AFFECTIONS    OF    THE    NECK  373 

hyperplasia  and  proliferation  of  the  endothelium  ("endarteritis).     The 
arteries  often  become  so  narrowed  that  thrombosis  is  inevitable. 

Chronic  Arteritis. — {Syn.:  Atheroma,  Arteriosclerosis). — As  a  pre- 
liminary to  the  consideration  of  aneurisms  a  short  description  of  the 
essential  features  of  this  important  disease  is  imperative.  It  is  essential 
that  this  disease  should  be  considered  as  a  malady  affecting  the  whole 
arterial  system,  and,  that  while  the  ravages  may  be  more  pronounced 
in  one  part  of  the  system,  e.g.,  the  large  arteries  (atheroma),  the  rest 
of  the  blood-vessels  are  profoundly  afifected  by  the  same  process.  In 
the  larger  arteries,  particularly  in  the  aorta,  typical  inflammatory 
processes  result  eventually  in  the  complete  destruction  of  parts  of  the 
intima  and  contiguous  parts  of  the  media,  in  loss  of  the  endothelial 
lining,  in  the  formation  of  so-called  atheromatous  ulcers  and  finally  in 
such  a  weakening  of  the  vessel  wall  that  the  external  coat  would  in- 
variably yield  to  the  blood  pressure  inside  the  vessels  if  it  were  not  for 
the  strengthening  of  the  inflamed  areas  by  the  deposition  of  lime  salts 
in  the  form  of  plates.  Even  so,  aneurisms  are  common  sequels  and 
atheromatous  changes  are  truly  looked  upon  as  the  forerunners  of  nearly 
all  the  aneurisms  of  spontaneous  origin.  In  the  small  arteries  the 
disease  usually  begins  in  the  muscular  coat  and  results  in  fatty  degen- 
eration and  often  in  calcification  of  the  cells  of  this  layer.  The  other 
coats  are  not  necessarily  involved  in  the  process  although  they  may  be 
thickened  and  their  elasticity  destroyed.  These  changes  can  be  recog- 
nized grossly  in  the  peripheral  arteries,  such  as  the  radial  and  temporal, 
the  vessels  becoming  tortuous  hard  and  ringed  or  bead-like.  In  other 
types  of  arteriosclerosis,  the  intima  is  primarily  afi'ected  by  a  prolifera- 
tive change  which  rapidly  leads  to  obHteration  of  the  lumen  of  the  ves- 
sel. Further,  the  process  often  affects  the  veins  equally  with  the  ar- 
teries and  both  artery  and  veins  and  perivascular  tissues  are  involved 
in  a  diffuse  sclerogenic  process.  This  latter  condition  can  be  demon- 
strated clearly  during  operations  for  ligature  of  markedly  atheromatous 
arteries. 


ANEURISMS 

Aneurisms  may  be  conveniently  divided  into  two  classes  according 
to  their  cause,  viz.:  (i)  spontaneous  aneurisms  resulting  from  disease 
of  the  artery  such  as  atheromatous  changes,  (2)  traumatic  aneurisms, 
resulting  from  stabs,  bullet  wounds,  etc. 


374  REGIONAL   SURGERY 

SPONTANEOUS  ANEURISMS  OF  SPECIAL  ARTERIES 

Innominate  Aneurism. — Aneurisms  of  this  vessel  occur  rather  in- 
frequently representing  about  3  per  cent,  of  all  aneurisms.  Matas 
divides  them  into  four  classes:  (i)  those  arising  from  the  artery  near 
its  origin,  the  aneurism  often  being  part  of  a  similar  condition  of  the 
aortic  arch;  (2)  those  arising  from  the  terminal  portion  of  the  vessel. 
In  these  the  carotid  or  subclavian  or  both  arise  from  the  wall  of  the 
sac;  (3)  those  occupying  the  entire  circumference  of  the  artery,  i.e.,  true 
fusiform  aneurisms;  (4)  those  where  the  dilatation  is  limited  to  the 
middle  portion  of  the  artery.  The  last  two  varieties  are  very  rare. 
Almost  invariably  the  aneurism  is  of  a  sacculated  type,  and  the  symp- 
toms that  result,  apart  from  those  of  an  intrinsic  character  such  as 
pulsation,  bruit,  etc.,  depend  on  the  position  of  the  sac  and  the  struc- 
tures it  presses  upon.  As  a  rule,  the  early  symptoms  are  entirely  intra- 
thoracic and  in  some  cases  remain  so  to  the  end;  but  in  most  instances 
the  sac  tends  to  grow  upward  into  the  neck  and  cervical  symptoms  are 
added.  In  typical  cases  of  cervical  extension  the  pulsating  tumor  oc- 
cupies the  lower  portion  of  the  neck,  behind  the  insertion  of  the  sterno- 
mastoid  muscle  which  is  often  tightly  stretched  over  the  sac.  If  the 
sac  is  large,  it  bulges  in  front  and  behind  the  sterno-mastoid  and  may 
reach  as  high  as  the  level  of  the  cricoid  cartilage.  In  advanced  cases 
and  especially  in  those  where  the  sac  arises  from  the  anterior  wall  of 
the  vessel,  erosion  of  the  sternum  and  the  inner  end  of  the  clavicle  may 
occur. 

Treatment. — The  rational  treatment  of  this  serious  affection  depends 
on  the  situation  of  the  sac  in  relation  to  the  trunk  of  the  artery.  In 
aneurisms  arising  from  the  distal  end  of  the  artery  it  might  be  possible 
to  apply  a  proximal  ligature  close  to  the  origin  of  the  artery  from  the 
aorta.  The  feasibility  of  such  a  procedure  should  first  be  determined 
by  a  careful  study  of  X-ray  pictures,  which  will  give  accurate  informa- 
tion as  to  the  situation  of  the  sac  and  the  probable  length  of  artery 
between  the  sac  and  the  aorta.  Even  in  cases  where  the  operation  is 
feasible  from  an  anatomical  point  of  view,  it  is  a  desperate  procedure 
and  the  mortality  must  necessarily  be  high.  In  all,  six  proximal  liga- 
tures of  the  innominate  artery  have  been  made  with  only  one  recovery 
(Burrell's  case).  It  is,  however,  only  fair  to  state  that  improved 
methods  of  obliterating  the  vessel  such  as  the  metal  clips  of  Halsted  or 
the  aluminum  bands  of  Matas  may  justify  the  operation.  Hitherto, 
failure  seems  to  have  depended  in  most  cases  on  the  ligature,  which  too 
often  cuts  its  way  through  the  walls  of  the  atheromatous  vessel,  and  pro- 


INFLAMMATORY   AFFECTIONS    OF   THE    NECK  375 

duces  fatal  hemorrhage.  Distal  ligature  is  the  operation  of  choice  in 
the  majority  of  cases.  The  common  carotid  and  the  subclavian  are 
simultaneously  tied,  beginning  with  the  carotid,  which  should  always  be 
first  compressed  with  a  detachable  clip  to  see  the  effect  on  the  brain. 
If  necessary,  some  of  the  branches  of  the  first  part  of  the  subclavian 
such  as  the  vertebral  and  internal  mammary  may  be  tied  at  the  same 
time.  The  results  have  been  surprisingly  good,  when  one  considers 
that  the  circulation  of  blood  through  the  aneurism  is  still  fairly  active 
after  the  vessels  have  been  Ugated.  The  percentage  of  cures  has  been 
placed  at  22  per  cent.  After  ligature,  the  pulsation  in  the  aneurismal 
sac  does  not  seem  to  be  much  diminished  at  first,  but  in  favorable 
cases  it  ceases  in  a  few  weeks.  In  one  of  the  writer's  cases  the  interval 
between  ligature  and  final  cessation  of  pulsation  and  bruit  was  almost  a 
month.  Cases  in  which  the  distal  ligature  has  proved  a  failure  can  be 
treated  by  the  methods  used  for  aortic  and  abdominal  aneurisms, 
viz.,  wiring  (Moore), needling  (Macewen)  or  the  Moore-Corradi  method. 

CAROTID  ANEURISMS 

I.  Common  Carotid  Aneurisms. — About  7  per  cent,  of  all  aneurisms 
occur  in  this  artery.  Spontaneous  aneurisms  are  more  commonly  met 
with  than  traumatic,  probably  because  wounds  of  the  artery  usually 
terminate  fatally.  About  one-third  occur  in  women,  a  contrast  with 
other  regions  where  aneurisms  are  about  eight  times  as  frequent  in 
men  as  in  women.  The  favorite  sites  for  the  aneurism  are  at  its  origin 
from  the  innominate  (right)  or  from  the  aorta  (left)  or  at  the  site  of 
bifurcation  into  the  internal  and  external  carotid  arteries.  The  right 
carotid  is  more  often  affected  than  the  left. 

Characteristics. — The  aneurisms  are  rounded  or  oval  in  shape  and 
usually  develop  from  below  upward  (Fig.  181) .  They  rarely  encroach  on 
the  middle  line  of  the  neck.  They  form  well-defined  pulsating  tumors, 
situated  along  the  line  of  the  vessel.  The  sterno-mastoid  is  usually 
spread  over  the  surface  of  the  sac.  They  have  a  tendency  to  compress 
and  displace  the  trachea  and  larynx  and  the  oesophagus  and  pharynx. 
They  may  become  so  closely  adherent  to  the  box  of  the  larynx  that 
every  pulsation  is  transmitted  to  it  and  an  upward  tracheal  tug  becomes 
evident.  Pressure  symptoms  also  result  from  interference  with  the 
vagus,  sympathetic,  phrenic  and  the  brachial  plexus.  Pressure  on  the 
internal  jugular  vein  may  cause  dilatation  of  the  vessels  of  the  upper 
part  of  the  neck. 


376 


REGIONAL   SURGERY 


Treatment. — All  methods,  such  as  rest  and  diet  (Tujffnell),  injec- 
tions, needhng, "  galvanopuncture,  digital  compression  of  the  artery, 
etc.,  have  been  tried,  but  little  need  be  said  of  them  except  that  most 


Fig.  i8i. — Aneurism  of  common  carotid. 


of  them  are  dangerous.  Usually  operation  is  the  method  of  choice 
and  the  technique  must  be  carefully  chosen  if  serious  cerebral  complica- 
tions would  be  avoided.  In  every  active  carotid  aneurism,  a  fair 
quantity  of  blood  is  still  passing  through  the  sac  to  the  internal  carotid 


INFLAMMATORY   AFFECTIONS    OF   THE   NECK  377 

trunk  and  so  to  the  brain.  The  amount  is  often  considerable  and  in 
cases  where  the  collateral  circulation  through  the  circle  of  Willis  is 
defective,  if  a  Hgaturc  is  placed  on  the  artery,  the  brain  supplied  by  the 
corresponding  internal  carotid  artery  is  starved  and  cerebral  anaemia 
results.  The  effect  of  this  is  often  disastrous,  hemiplegia  and  even 
fatal  coma  making  their  appearance  within  a  short  period  after  the 
artery  is  obhterated.  It  is  found  that  occlusion  of  the  common  carotid 
artery  is  so  dangerous  a  procedure  that  one-quarter  of  all  the  cases 
show  dangerous  symptoms  and  about  lo  per  cent,  die  (Matas).  After 
the  age  of  40  the  dangers  are  always  increased,  because  this  period 
of  life  is  one  of  a  progressive  arterial  degeneration,  which  embarrasses 
the  collateral  circulation.  In  order  to  avoid  the  serious  effects  of  cere- 
bral ischa^mia,  it  is  necessary  to  adopt  some  method  of  obliterating  the 
vessels  temporarily  and  which  will  not  injure  the  artery  permanently 
at  the  site  of  compression;  so  that,  if  cerebral  symptoms  develop,  the 
compression  may  be  removed  and  the  blood  allowed  to  circulate  along 
the  vessel  once  more.  It  has  been  stated  by  Bernhardt  that  brain 
tissue  will  not  die  if  the  circulation  is  restored  within  24  to  48  hours 
after  it  has  been  cut  off.  The  time  of  complete  restoration  is  prob- 
ably much  shorter,  and  complete  stoppage  of  circulation  for  12  hours 
would  be  apt  to  injure  the  gangHon  cells  permanently.  Happily,  in 
cUnical  cases  cerebral  symptoms  usually  appear  in  a  few  hours  and 
the  warning  comes  early  enough  to  enable  us  to  avoid  serious  conse- 
quences. Perhaps  the  simplest  method  of  compressing  the  carotid 
artery  lies  in  the  aluminum  strips  advised  by  Matas;  if  they  are  used 
delicately  it  is  probable  that  compression  may  be  used  in  a  reasonably 
healthy  carotid  artery  for  48  hours  without  damage  to  the  intima. 
The  technique  of  the  operation  is  as  follows:  if  the  aneurism  is  so 
situated  that  the  internal  carotid  artery  can  be  exposed  safely  on 
the  distal  side  of  the  sac,  an  aluminum  clip  is  placed  on  this  vessel. 
The  clip  is  pressed  tightly  enough  to  obstruct  the  lumen  completely 
without  injury  to  the  intima.  If  brain  symptoms  occur,  the  cHp  is 
removed.  A  distal  ligature  such  as  this  will  often  cure  the  case.  If, 
however,  the  aneurism  still  pulsates,  another  ligature  or  clip  can  be 
applied  on  the  proximal  side  of  the  sac  at  a  subsequent  operation,  after 
which  consolidation  will  invariably  follow.  In  the  rare  cases  where 
pulsation  still  continues  the  aneurismal  sac  may  be  opened  and  oblit- 
erated by  suture  of  the  open  vessel  mouths  and  sides  of  the  sac  (Matas). 
In  aneurisms  situated  very  high  up,  distal  occlusion  of  the  internal 
carotid  is  often  impossible.     This  is  to  be  regretted,  because  it  is  a  great 


378  REGIONAL   SURGERY 

safeguard  against  the  escape  from  the  sac  of  the  aneurism,  of  soft 
clots  which  might  form  serious  emboHsms  of  the  middle  cerebral  artery. 
Under  these  circumstances  we  must  be  contented  with  proximal  occlu- 
sion. Direct  attack  on  the  aneurismal  sac  by  one  of  the  open  methods 
(Antyllus,  Matas,  or  extirpation)  is  admissable  only  in  cases  where 
failure  has  followed  the  method  above  outlined.  Constructive  endo- 
aneurismorraphy  would  be  especially  indicated  where  the  collateral 
circulation  is  shown  to  be  inadequate.  But  if  clotting  occurred  in  the 
reconstructed  vessel  a  fatal  result  might  follow.  Partial  clotting  in  a 
reconstructed  artery  might  result  in  fatal  emboHsm  in  the  cerebral 
artery.  Excision  of  the  sac  seems  to  be  very  dangerous  and  unnecessary. 
In  cases  where  the  wall  of  the  sac  is  adherent  to  important  structures 
it  should  be  discountenanced.  In  other  cases  it  is  also  unjustifiable 
because  the  simpler  methods  are  very  sure  and  much  safer. 

Internal  Carotid  Aneurisms. — Aneurisms  of  the  internal  carotid 
may  be  divided  into  two  varieties  according  to  their  anatomical 
situation. 

1.  Intracranial  Aneurisms. — These  will  be  described  elsewhere. 

2.  Extracranial  Aneurisms. — These  occur  anywhere  between  the 
origin  of  the  artery  and  its  entrance  into  the  carotid  canal.  They  are 
very  rare.  They  have  been  divided  into  three  groups  (Matas):  (i) 
traumatic  false  aneurisms;  (2)  erosion  aneurisms,  caused  by  the  ulcera- 
tion of  the  internal  carotid  artery  in  abscess  cavities  (tonsillar  and 
retropharyngeal) ;  (3)  true  spontaneous  aneurisms  arising  from  athero- 
matous disease. 

Most  of  the  spontaneous  aneurisms  arise  from  the  bulbous  part  of 
the  artery  near  its  origin.  They  form  pulsating  swellings  under  the 
upper  portion  of  the  sterno-mastoid  muscle.  They  cause  pressure 
on  the  pharyngeal  wall  and  bulge  into  the  pharyngeal  and  faucial  spaces. 
They  ought  to  be  recognized  easily  by  their  pulsation  and  the  absence 
of  inflammatory  symptoms.  Still,  very  few  have  been  diagnosed  cor- 
rectly, the  majority  being  mistaken  for  growths  and  tonsillar  abscesses, 
with  serious  results.  Erosion  aneurisms,  on  the  other  hand,  which 
develop  in  abscess  cavities  are  very  difficult  of  recognition,  because  the 
initial  history  is  one  of  inflammation,  the  pulsation  being  a  later  de- 
velopment. Pulsation  is  often  slight,  owing  to  the  blood  sac  being 
surrounded  by  inflamed  tissue.  Fatal  results  have  followed  incisions 
into  these  aneurisms,  the  surgeon  being  under  the  impression  that  the 
case  was  one  of  abscess. 

Treatment. — The  same  precautions  must  be  used  in  treating  these 


INFLAMMATORY   AFFECTIONS    OF   THE    NECK  379 

aneurisms  that  have  been  emphasized  in  discussing  those  occupying  the 
common  carotid  artery.  If  possible,  the  internal  carotid  artery  should 
be  compressed  by  a  cHp  which  can  be  removed  if  cerebral  symptoms 
appear.  If  it  is  not  feasible  to  obliterate  the  internal  carotid,  a  clip 
must  be  put  on  the  common  carotid  and  this  can  be  supplemented  by 
ligature  of  all  the  branches  of  the  external  carotid  that  are  accessible, 
to  prevent  blood  reaching  the  sac  by  the  open  collateral  channels.  In 
cases  of  emergency  where  the  internal  carotid  artery  has  been  wounded 
while  opening  a  tonsillar  abscess  or  where  an  erosion  aneurism  has 
been  opened,  the  wound  should  be  plugged  and  the  common  carotid 
artery  exposed  and  compressed  provisionally  while  search  is  made  for 
the  bleeding  point,  which  should  be  secured  if  it  can  be  reached.  Fail- 
ing to  reach  the  bleeding  point,  the  common  carotid  should  be  hgatured 
permanently  and  in  addition  the  trunk  of  the  external  carotid  should  be 
obliterated  to  cut  off  the  collateral  circulation  (Wyeth).  Finally,  the 
wound  should  be  firmly  packed.  Direct  operations  are  too  dangerous 
to  be  employed  in  this  situation. 

Aneurisms  of  the  External  Carotid  and  Its  Branches. — Aneurisms 
of  the  main  trunk  are  rarer  than  those  of  the  internal  carotid.  It  is  very 
difficult  to  distinguish  them  from  aneurisms  of  the  termination  of  the 
common  carotid  or  from  those  of  the  beginning. of  the  internal  carotid. 
Aneurisms  of  the  separate  branches  of  the  external  carotid  are  occasion- 
ally met  with. 

Treatment. — The  treatment  of  aneurism  of  the  trunk  of  the  artery 
will  depend  on  its  position.  If  possible,  the  external  carotid  artery 
should  be  tied  proximal  to  the  aneurism.  It  should  be  remembered, 
however,  that  ligature  too  near  its  origin  is  dangerous  because  clots 
may  be  detached  from  the  site  of  ligature  and  swept  up  the  internal 
trunk  into  the  middle  cerebral.  If  the  external  carotid  cannot  be  tied, 
a  clamp  should  be  placed  temporarily  on  the  common  carotid  to  con- 
trol hemorrhage,  after  which  the  aneurism  should  be  opened  and  ob- 
literated by  the  intrasaccular  method.  Temporary  compression  of  the 
internal  carotid  renders  this  operation  less  bloody.  Distal  ligature  of 
its  branches  would  be  worth  consideration,  if  all  of  them  could  be 
exposed  safely. 

Aneurism  of  the  Subclavian  Artery. — Aneurisms  are  most  fre- 
quently met  arising  from  the  third  part  of  the  artery,  very  rarely  from 
the  second  part.  They  are  as  frequent  as  those  of  the  common  carotid, 
are  more  common  in  men  and  usually  affect  the  right  artery.  Spon- 
taneous aneurisms  are  much  more  common  than  traumatic,  in  which 


380  REGIONAL   SURGERY 

respect  they  resemble  those  of  the  common  carotid.  As  to  symptoms, 
those  arising  from  the  first  part  produce  symptoms  exactly  like  those 
of  the  innominate  at  its  bifurcation;  whereas  those  arising  from  the 
third  part  resemble  axillary  aneurisms  and  have  a  tendency  to  grow 
downward  into  the  axillary  space.  The  nature  of  the  swelling  is  easily 
recognized  from  the  intrinsic  symptoms,  pulsation,  bruit,  etc.,  and  from 
the  extrinsic  symptoms,  pressure  on  nerves,  veins,  trachea,  etc.  The 
tendency  to  spontaneous  cure  seems  to  be  small,  the  tumor  usually 
rupturing  either  externally  or  into  the  trachea  or  pleura.  In  some 
cases  a  differential  diagnosis  between  aneurism  and  pulsating  sarcoma 
of  the  clavicle  may  have  to  be  made,  a  task  which  is  often  dif6.cult. 

Treatment. — As  Matas  remarks,  probably  more  remedies  have  been 
tried  in  this  class  of  aneurism  than  in  any  other.  Non-operative  meth- 
ods are  of  Httle  use  although  needling  by  Macewen's  method  has  accom- 
pHshed  a  few  cures.  The  plan  of  surgical  attack  depends  on  the  situa- 
tion of  the  aneurism,  whether  it  is  situated  inside  or  outside  the  scal- 
enus-anticus  muscle.  In  the  former,  ''intrascalenic  aneurisms," 
proximal  Ugature  of  the  subclavian  is  almost  an  impossibility.  The 
innominate  might  be  ligatured,  but  this  is  always  a  formidable  opera- 
tion. It  is  probably  far  wiser  to  use  distal  ligatures  applied  to  the  com- 
mon carotid  and  the  third  part  of  the  subclavian  respectively.  The 
results  are  usually  good.  In  the  "  extrascalenic  aneurisms,"  a  proxi- 
mal hgature  should  be  appHed  to  the  artery  just  outside  the  scalenus- 
anticus.  This  will  necessarily  be  close  to  the  Sac.  If  cure  does  not  re- 
sult, the  aneurismal  sac  should  be  opened  and  intrasaccular  suture  used. 
Matas  advises  the  immediate  opening  of  the  sac  as  soon  as  the  proximal 
circulation  is  secured.  He  is  emphatic  about  its  superiority  to  extirpa- 
tion which  endagers  surrounding  structures.  The  mortality  ought 
not  to  be  heavy.  In  aneurisms  outside  the  scalenus-anticus  it  is  less 
than  10  per  cent.  (Savariand).  The  danger  of  gangrene  in  the  arm  is 
slight.  The  collateral  circulation  through  the  scapular  anastomoses  is 
usually  well  developed  and  if  care  is  taken,  during  the  operation,  not 
to  injure  the  posterior  scapular  artery  which  often  arises  from  the  third 
part  of  the  subclavian,  the  chances  of  success  are  greater. 

Arterio-venous  Aneurisms. — The  time  honored  classification  of 
these  aneurisms  into  two  classes,  viz. :  (i)  The  aneurismal  varix  and  (2) 
the  varicose  aneurism  is  perfectly  satisfactory.  In  the  former,  the  walls 
of  the  vein  and  artery  are  adherent  and  a  fistulous  opening  passes  di- 
rectly from  the  lumen  of  the  artery  into  that  of  the  vein.  In  the  latter, 
the  artery  and  vein  are  separated  from  one  another  by  an  aneurismal 


INFLAMMATORY   AFFECTIONS    OF   THE   NECK 


381 


sac^of  adventitious  formation  into  which  the  artery  and  vein  open  by 
separate  apertures.  A  very  important  modification  of  this  conception 
of  a  varicose  aneurism  is  seen  in  cases  where  both  artery  and  vein  open 
into  the  aneurismal  sac  by  a  proximal  and  distal  aperture.  This  con- 
dition occurs  when  both  artery  and  vein  have  been  divided  by  the  injury 
and  an  aneurismal  sac  has  developed  between  the  proximal  and  distal 

AViAV  A2V  A3V 


D 


r1' 


M 


Fig.  182. — The  three  principal  forms  of  arterio-venous  aneurism,  i.  Arterio-venous 
fistula  (a);  arterio-venous  aneurism  with  venous  sac,  varixaneurismaticus  (i).  2.  Arterio- 
venous aneurism  with  false  intermediate  sac,  aneurisma  varicosum.  3.  Arterio-venous 
aneurism  with  arterial  sac,  secondary  arterio-venous  aneurism.     {Lexer-Bevan.) 

ends  of  the  vessels,  a  little  blood  being  still  propelled  to  the  periphery 
along  the  artery,  and  venous  blood  still  returning  to  the  aneurismal  sac 
along  the  peripheral  venous  channel.  In  addition,  other  minor,  gross, 
pathological  changes  may  occur,  such  as  the  formation  of  a  saccule  in  the 


A     I      V 


A      V      2 


A  3  V 


A 


b  d 


A 


m 


nl 


A 


Gifb 


Fig.  183. — Special  forms,  i.  Arterio-venous  aneurism  with  false  sac  and  varix  on 
outer  side  of  vein.  (Single  injury  of  artery,  double  injury  of  the  vein.)  2.  Arterio-venous 
aneurism  with  direct  communication  in  (a)  and  with  a  false  intermediate  sac  in  {b)  and 
with  a  false  arterial  aneurism.  (Single  injury  of  vein,  double  injury  of  artery.)  3.  Arte-, 
rio-venous  fistula,  following  double  injuries  of  both  vessels.  The  sacs  lie  opposite  each 
other.     {Lexer-Bevan.) 

vein  opposite  the  fistulous  opening  and  even  the  formation  of  an  arte- 
rial saccule  (aneurism)  opposite  the  fistula.  Figs.  182  and  183  illus- 
trate every  anatomical  variety. 

Arterio-venous  aneurisms  of  the  arteries  of  the  neck  are  rare  for 
the  same  reason  that  traumatic  aneurisms  are,  viz.,  because  the  major- 
ity of  patients  receiving  wounds  likely  to  terminate  in  this  condition  die 
from  hemorrhage.     They  have  been  met  with  between  the  common  car- 


382  REGIONAL   SURGERY 

otid,  the  internal  carotid  and  (rarely)  the  external  carotid  arteries  re- 
spectively and  the  jugular  vein,  and  rarely  between  the  subclavian  ar- 
tery and  vein. 

Arterio-venous  Aneurisms  of  the  Conunon  Carotid  Artery  and  the 
Jugular  Vein. — As  mentioned  above  these  are  rare.     The  cause  is  usu- 


FiG.  184. — Varicose  aneurism  type  of  arterio-venous  aneurism  of  left  common  femoral 
artery  and  vein,  showing  the  application  of  this  class  of  aneurisms  of  the  Matas  method  of 
operating  upon  ordinary  aneurisms.  The  opening  of  the  femoral  artery  into  the  corninon 
aneurismal  sac  is  shown  on  the  right,  with  interrupted  Lembert  gut  sutures  in  position, 
ready  to  be  tied.  The  opening  of  the  femoral  vein  is  seen  on  the  left,  with  similar  Lembert 
sutures  in  position.  On  the  left  of  the  sac  two  gut  sutures  are  in  the  act  of  being  placed, 
which,  when  tied,  will  approximate  the  roof  of  the  sac  (including  skin  and  intervening 
tissues,  which  are  not  here  shown)  to  the  floor  of  the  sac.  Similar  sutures  will  approximate 
the  roof  and  floor  of  the  sac  upon  the  right.     {Bickham,  in  Ann.  of  Surg.,  May,  1904.) 

ally  a  stab,  gunshot  or  incised  wound.  The  primary  symptoms  are 
those  of  hemorrhage  which  is  controlled  by  pressure.  The  close  jux- 
taposition of  the  vessels  favors  agglutination,  but  the  opening  between 
the  vessels  persists  and  arterial  blood  pours  from  the  artery  into  the 
vein.  In  the  course  of  time  it  is  found  that  the  swelling  which  at  first 
consisted  of  extravasated  blood,  does  not  disappear  but  begins  to  show 
distinct  signs  of  pulsation.  If  the  shape  of  the  swelling  is  irregularly 
round  and  of  firm  consistence  and  if  on  pressure  it  becomes  smaller  but 


INFLAMMATORY   AFFECTIONS    OF    THE    NECK  383 

does  not  disappear,  it  is  probably  a  varicose  aneurism;  but  if  it  is  oval 
in  shape,  soft  and  semifluctuant  and  can  be  obliterated  by  pressure,  it 
is  probably  an  aneurismal  varix.  In  both  cases  marked  pulsation  can 
be  seen  and  felt  in  the  jugular  vein.  Palpation  reveals  a  prolonged 
thrill.     On  auscultation  a  murmur  is  heard  that  has  been  compared 


Fig.  185. — Aneurismal  varix  type  of  arterio-venous  aneurism  of  left  common  femoral 
artery  and  vein,  showing  the  application  to  this  class  of  aneurisms  of  the  Matas  method 
of  operating  upon  ordinary  aneurisms.  The  opening  of  the  femoral  artery  into  the  vari- 
cosed  vein  is  shown,  with  interrupted  Lembert  gut  sutures  in  position,  ready  to  be  tied. 
The  longitudinal  incision  in  the  vein  or  approaching  the  arterio-venous  opening  (and  which 
is  here  made  somewhat  unnecessarily  long)  is  shown  in  the  act  of  being  closed  by  two 
methods  of  suturing — above,  by  the  continuous  Lembert  of  the  outer  coats;  below,  by 
interrupted  ordinary  sutures  of  the  outer  coats.     {Bickman,  in  Ann.  of  Surg.,  May,  1914.) 

variously  to  the  hum  of  distant  machinery,  to  a  fly  in  a  paper  bag,  etc. 
Owing  to  the  obstruction  to  the  flow  of  venous  blood  from  the  brain, 
various  cerebral  symptoms  are  noticed,  such  as  headache,  giddiness, 
faintness,  dimness  of  sight,  etc.  The  constant  roaring  that  the  patient 
hears  makes  him  very  irritable,  restless  and  sleepless. 

Prognosis. — The   course   of     aneurismal   varix   is   usually   benign. 
There  is  practically  no  tendency  for  the  swelling  to  enlarge  and  in  time 


384  REGIONAL   SURGERY 

the  vein  accommodates  itself  in  a  remarkable  manner  to  the  increase  in 
blood  pressure.  The  cerebral  circulation  also  undergoes  compensation. 
In  varicose  aneurisms  the  prognosis  must  be  more  guarded,  although 
although  progressive  enlargement  and  rupture  of  the  sac  are  rare  ter- 
minations.    Still,  one  must  never  forget  that  in  both  varieties  the  per- 


FiG.  186. — Same  as  Fig.  185,  showing  a  continuous  Lembert  gut  suture,  which,  having 
been  passed  through  the  outer  coats  of  the  thickened  vein  at  the  angle  of  junction  of  vein 
and  artery  and  knotted,  is  passed  on  between  the  coats  of  the  vein  until  its  varicosed  cavity 
is  entered  very  near  one  end  of,  and  immediately  above,  the  first  tier  of  interrupted  sutures, 
and  is  then  made  to  bury-in  this  first  tier  and  itself  in  continuous  Lembert  fashion  and, 
emerging  at  the  opposite  angle  of  junction  of  vein  and  artery,  is  tied  in  the  same  manner 
as  at  its -entrance;  this  suture  is  not  yet  tightened  throughout.  (Bickham,  in  Ann.  of 
Surg.,  May,  1904.) 

ipheral  circulation  always  suffers  both  from  lack  of  arterial  blood  and 
from  obstruction  to  venous  return.  There  is  practically  no  tendency  to 
spontaneous  cure  in  either  condition. 

Treatment. — Owing  to  the  tolerance  of  the  individual  to  these  con- 
ditions, operative  interference  should  not  be  undertaken  unless  there  is 
sufficient  reason.  The  chief  indications  for  operative  treatment  are 
(i)  progressive  enlargement  of  the  aneurism,  (2)  symptoms  of  venous 
stasis  or  dangerous  obstruction  of  the  venous  circulation.  It  must 
always  be  remembered  that  both  artery  and  vein  are  involved  in  the  proc- 
ess and  that  any  operation  which  results  in  obliteration  of  either  ves- 
sel may  cause  serious  cerebral  symptoms;  therefore,  an  operation  must 


INFLAMMATORY  AFFECTIONS   OF   THE   NECK 


385 


be  chosen  which  will  close  the  anastomotic  opening  without  closing  the 
lumen  of  either  artery  or  vein.  This  can  be  done  in  a  very  simple  man- 
ner if  the  main  circulation  can  be  controlled  temporarily.  An  incision 
is  made  over  the  aneurismal  varix  or  over  the  sac  of  a  varicose  aneurism. 
Careful  dissection  of  the  vessels  will  lay  bare  the  anastomotic  opening 


Fig.  187. — Varicose  aneurism  of  left  common  femoral  artery  and  vein,  treated  by  ex- 
cision of  the  sac,  followed  by  suturing  of  the  openings  in  the  vessels.  Upon  the  right,  a 
small  elliptical  piece  of  the  sac  is  shown  connected  with  the  arterial  opening,  with  the  first 
tier  of  interrupted  Lembert  gut  sutures  in  position,  ready  to  be  tied.  Upon  the  left,  a 
similar  elliptical  piece  of  sac  has  been  left  connected  with  the  venous  opening.  The  first 
row  of  Lembert  sutures  has  been  tied,  and  a  second  tier  of  ordinary  sutures  through  all  the 
coats  is  being  applied,  burying  in  the  first  tier.  Fig.  187  is  the  same  as  Fig.  184,  with  the 
sac  excised.     {Bickham,  in  Ann.  of  Surg.,  May,  1904.) 


in  the  former.  The  artery  and  vein  are  then  isolated  by  severing  their 
connections  and  the  separate  openings  closed  carefully  by  sutures  (Figs. 
184,  185,  186  and  187).  In  the  latter,  the  sac  is  opened  and  the  open- 
ings into  the  artery  and  vein  exposed  and  sutured  as  in  the  operation  of 
aneurismorraphy.  Such  operations  will  of  necessity  be  very  infrequent 
in  the  neck,  owing  to  the  dijSiculty  in  controlhng  the  circulation  thor- 
oughly enough  to  secure  a  dry  field. 

Arterio-venous  aneurisms  of  the  internal  carotid  are  \'ery  rare. 
Their  symptomatology  and  the  principles  underlying  their  treatment 
are  identical  with  those  of  the  common  carotid. 
as 


386  REGIONAL    SURGERY 

Arterio-venous  aneurisms  of  the  subclavian  artery  and  vein  are 

also  rare.  Matas  reports  one  successfully  treated.  The  opening  in 
the  vein  was  sutured,  but  he  was  forced  to  ligate  the  artery  above  and 
below  the  opening. 

DISEASES  OF  THE  MUSCLES  OF  THE  NECK 

Atrophy." — Atrophy  of  the  muscles  of  the  neck  may  arise  from  any 
of  the  following  causes: 

1.  From  Disease. — This  is  usually  produced  by  ankylosis  caused 
by  tuberculosis  of  the  cervical  vertebrae.  The  muscles  become  at- 
tenuated and  wasted  and  much  of  the  muscular  tissue  disappears. 
The  reaction  of  degeneration  is  not  present. 

2.  From  Inflammation. — The  sterno-mastoid  muscle  is  most  often 
affected.  Usually  the  inflammation  is  caused  by  injury  which  ruptures 
some  of  the  fibers  of  the  sterno-mastoid  causing  a  hematoma.  Most 
of  these  cases  occur  in  newly  born  children  and  result  from  injuries 
received  during  parturition.  The  inflammatory  process  set  up  by 
the  rupture  of  muscle  results  in  the  absorption  of  the  extravasated 
blood  and  in  the  replacement  of  muscular  fibers  by  scar  tissue.  The 
resulting  contraction  is  often  the  cause  of  wry-neck. 

3.  After  division  of  the  nerves  supplying  muscles,  which  frequently 
occurs  during  operation  and  through  accidents,  atrophy  invariably 
occurs.  After  division  of  the  hypoglossal,  hemiatrophy  of  the  tongue 
always  follows.  The  sterno-mastoid  and  trapezius  undergo  partial 
atrophy  only,  after  division  of  the  spinal  accessory,  because  they  re- 
ceive a  separate  nervous  supply  from  the  cervical  plexus.  If  both 
sources  of  nerve  supply  are  divided,  total  atrophy  is  inevitable.  When 
the  muscles  are  cut  off  from  the  trophic  centers,  the  reaction  of  de- 
generation soon  appears  and  the  muscle  undergoes  complete  degenera- 
tion, the  fibers  disappearing  eventually,  their  place  being  taken  by 
fibrous  tissue  infiltrated  with  fat. 

4.  Poliomyelitis  in  some  rare  cases  affects  the  anterior  horns  of 
the  upper  cervical  region  of  the  cord.  The  result  is  paralysis  and 
atrophy  of  some  of  the  muscles  of  the  neck. 

Myositis. — Simple  myositis  occurs  in  the  neck  usually  as  the  result 
of  traumatism.  Hematogenous  myositis  (Mikulicz)  is  a  common 
result  of  injuries  of  the  sterno-mastoid  received  during  parturition  and 
is  a  common  cause  of  congenital  torticollis. 

Infective  Myositis. — Usually  two  forms  of  this  disease  are  de- 
scribed: (i)  direct,  infective  myositis;  (2)  metastatic,  infective  myo- 


INFLAMMATORY   AFFECTIONS    OF   THE   NECK  387 

sitis.  (i)  Direct  infection  may  occur  from  disease  of  neighboring 
structures  such  as  a  lymphatic  gland  or  the  vertebrae.  Extension  to 
the  muscles  is  much  less  frequent  in  acute  infection  (staphylococcic  and 
streptococcic)  than  in  the  chronic  (tuberculous).  In  acute  ab- 
scesses of  the  neck  the  muscle  may  be  bathed  in  virulent  pus  without 
having  its  vitality  impaired  in  the  least  degree.  In  tuberculosis  of 
the  lymphatic  glands  we  often  find  the  sterno-mastoid  extensively  in- 
filtrated with  the  disease. 

Metastatic  infections  are  very  rare  in  the  muscles  of  the  neck. 
Apart  from  the  typical  pyaemic  processes  they  are  met  with  in  in- 
dividuals where  resistance  is  at  a  low  ebb  from  want,  exposure  or  ex- 
cesses. They  are  more  frequently  met  with  in  the  muscles  of  the 
thigh  and  result  in  the  formation  of  abscesses  which  often  contain  a 
thin  sanious  or  grumous  pus.  The  cavities  are  often  large  and  ragged. 
The  constitutional  symptoms  are  often  severe,  and  in  many  cases  con- 
valescence is  slow  and  tedious  or  a  fatal  issue  may  result.  A  curious 
form  of  metastatic  inflammation  of  muscles  has  been  described,  which 
is  characterized  by  the  presence  of  pain  in  a  number  of  muscles  and  the 
appearance  of  indurated  areas  with  oedema  over  them.  The  affected 
muscles  are  often  contracted.  Incision  into  these  areas  fails  to  show 
any  pus.  Recovery  is  the  rule.  To  this  disease  the  name  acute 
polymyositis  has  been  given. 

Myositis  Ossificans  Progressiva. — This  disease,  the  cause  of  which 
is  unknown,  usually  begins  in  the  muscles  of  the  neck  and  back.  They 
become  suddenly  swollen  and  painful,  and  as  the  swelling  subsides  in- 
duration is  observed,  which  becomes  bony  in  consistency.  One  at- 
tack follows  another,  different  groups  of  muscles  being  involved  until 
nearly  every  group  of  muscles  in  the  body  may  be  affected.  The  dis- 
ease is  always  progressive,  and  if  the  patient  lives  long  enough  all  the 
muscles  of  the  body  may  become  ossified. 

Tuberculosis  of  Muscles. — The  muscles  may  be  afi'ected  with 
tuberculosis  in  one  of  two  ways:  (i)  by  direct  extension  of  the  disease 
from  a  neighboring  structure  such  as  a  lymphatic  gland  or  the  vertebra, 
or  (2)  the  tuberculous  infection  may  be  metastatic,  the  primary  in- 
fection being  usually  in  a  distant  gland  (bronchial)  or  organ.  The 
former  condition  is  by  far  the  more  common.  In  advanced  cases  of 
tuberculosis  of  the  cervical  lymph  nodes,  the  sterno-mastoid  especially 
and  any  of  the  deeper  muscles,  such  as  the  splenius  capitis,  digastric  and 
mylohyoid,  are  often  infiltrated  to  such  an  extent  that  removal  of  large 
parts  of  them  is  imperative  during  the  radical  operation  on  the  lymph 


388  REGIONAL   SURGERY 

nodes.  In  metastatic  infections,  which  are  quite  rare,  the  disease  may 
show  itself  as  one  or  more  soHtary  nodules,  or  it  may  assume  the  miliary 
form.  The  nodules  pass  through  every  stage  of  induration,  caseation 
and  abscess  formation.  Sometimes  a  whole  muscular  belly  may  be 
involved.  The  treatment  should  be  wide  excision  of  the  affected  area 
and  in  some  cases  excision  of  the  whole  muscle. 

Syphilitic  Affections  of  Muscle. — In  the  early  stages  of  syphiHs, 
muscular  affections  are  rare  and  are  usually  shown  by  the  presence  of 
vague  distressing  pains  of  a  rheumatic  character,  and  in  rare  instances 
by  the  appearance  of  contractures.  We  have  no  knowledge  of  the 
pathology  of  these  early  symptoms,  but  they  are  probably  produced  by 
circulatory  disturbances.  The  contractures  affect  the  biceps  and  other 
long  muscles  of  the  body  and  persist  for  a  long  period  if  the  case  is 
untreated.  Under  specific  treatment,  the  symptoms  disappear  rapidly. 
In  the  tertiary  stages  of  syphilis  muscular  affections  are  very  common 
and  appear  usually  under  one  of  these  forms,  (i)  The  syphilitic 
inflammation  affects  the  muscles  in  a  diffuse  form  (diffuse  S3^hilitic 
myositis).  The  muscles  affected  show  a  diffuse  hardening  and  swelling, 
occupying  the  greater  part  of  their  extent  and  attended  with  pain  and 
loss  of  function.  If  untreated,  the  muscular  tissue  undergoes  atrophy 
and  sclerosis  follows.  In  the  neck  the  sterno-mastoid  is  usually  affected. 
(2)  Gummatous  infiltration  of  muscle  is  probably  the  most  common 
manifestation  of  the  later  stages  of  syphilis.  It  is  said  to  be  a  common 
manifestation  in  hereditary  syphilis  and  occurs  most  frequently  in  the 
sterno-mastoid.  The  changes  noticed  are  those  seen  in  gummata 
generally,  viz.,  induration,  usually  of  a  slow,  painless  character,  followed 
by  softening  and  ulceration.  If  untreated,  the  resulting  necrosis  may 
be  extensive,  and  serious  deformities  may  result.  Even  if  treated  suc- 
cessfully before  ulceration  occurs,  much  muscular  tissue  is  sure  to  be 
destroyed  and  will  be  replaced  by  scar  tissue,  the  result  being  a  non- 
contractile  rigid  cord  instead  of  a  living  muscle.  Acquired  torticolUs 
may  result  from  a  gumma  of  the  sterno-mastoid. 

Peirasitic  Disease. — With  the  exception  of  actinomycosis  (see  p. 
339),  parasitic  diseases  are  very  rare.  Hydatid  cysts,  which  are  of  rare 
occurrence  in  muscles,  have  been  found  in  the  muscles  of  the  neck. 
Trichiniasis  occurs  in  these  muscles  as  part  of  the  general  systemic 
infecion  in  this  disease. 

Injuries  to  Muscles. — Open  Wounds. — These  may  be  incised  or  of 
the  gunshot  variety.  Apart  from  possible  injury  to  vital  structures 
they  are  of  little  consequence.     They  are  Uable  to  infection  which  must 


INFLAMMATORY   AFFECTIONS    OF    THE   NECK  389 

be  guarded  against  by  the  usual  precautions.  If  the  muscular  fibers 
are  extensively  severed,  the  ends  will  retract  and  sutures  may  be  required 
to  prevent  serious  deformity.  In  this  connection  mention  should  be 
made  of  the  importance  of  careful  suture  of  the  platysma  after  trans- 
verse incised  wounds  of  the  neck,  to  prevent  deformity. 

Subcutaneous  Injuries. — Partial  or  complete  rupture  of  the  muscular 
fibers  may  result  from  injuries.  The  accident  may  be  produced  by  a 
direct  injury  such  as  a  blow  or  crush  or  kneading,  or  it  maybe  brought 
about  by  vigorous  muscular  contraction  against  resistance.  In  the 
neck  the  sterno-mastoid  muscle  is  the  one  usually  affected.  In  new-born 
children,  and  especially  after  difl&cult  labors,  the  sterno-mastoid  muscle 
is  often  seriously  bruised  and  ruptured.  A  hematoma  results.  As 
time  passes  it  becomes  absorbed  and  in  the  majority  of  cases  no  evil 
results,  but  in  some  instances  permanent  cicatricial  changes  follow 
and  the  sterno-mastoid  becomes  permanently  contracted,  producing 
one  of  the  varieties  of  wry-neck.  In  adults,  rupture  of  the  sterno- 
mastoid  is  a  rare  injury.  It  is  usually  partial.  If  many  of  the  trans- 
verse fibers  are  divided,  a  deep  groove  is  both  visible  and  palpable. 
Much  blood  is  poured  out  and  for  a  time  the  true  diagnosis  may  be  ob- 
scure. Later  on,  as  the  blood  is  absorbed,  a  transverse  depression 
appears  in  the  neck.  The  treatment  will  depend  on  the  extent  of 
the  rupture.  If  extensive,  the  muscular  fibers  should  be  reunited  with 
sutures.  Open  operation,  however,  is  only  necessary  for  cosmetic 
purposes,  as  the  movements  of  the  neck  are  not  necessarily  impaired 
even  after  complete  rupture  or  division  of  the  sterno-mastoid. 

Tumors  of  Muscles. — Primary  tumors  of  muscles  are  rare.  A 
fair  number  of  cases  of  angioma  have  been  described  as  occurring 
in  the  sterno-mastoid  muscle.  Perhaps  the  most  common  primary 
tumor  occurring  in  the  muscles  of  the  neck  is  sarcoma.  The  sterno- 
mastoid  muscle  is  the  usual  seat  of  the  disease.  The  tumor  may  be  of 
the  round-  or  spindle-celled  variety  and  may  show  evidence  of  myxo- 
matous degeneration  and  contain  cystic  cavities.  It  may  occupy  a  con- 
siderable extent  of  the  muscle.  In  the  early  stages,  it  is  entirely 
confined  to  the  muscular  sheath  and  shows  no  tendency  to  extend  be- 
yond it.  Later,  it  will  infiltrate  the  neighboring  tissues.  The  treatment 
should  be  extensive  removal.  The  only  wise  course  to  pursue  is  to 
remove  the  muscle  in  a  cleanly  manner  from  end  to  end. 

Secondary  Tumors  of  Muscle. — All  cancers  of  muscle  are  secondary. 
In  the  neck,  they  invariably  result  from  direct  extension  of  the  growth 
from  the  primary  focus  (mouth,  oesophagus,  larynx)  or  from  metastatic 


39©  REGIONAL   SURGERY 

deposits.  True  metastatic  deposit  in  the  muscles  from  cancer  at  a  dis- 
tance is  very  rare,  although  the  muscles  are  occasionally  infected  by 
extension  of  metastatic  growths  in  the  bones  (vertebrae,  clavicle,  skull). 

TUMORS  OF  THE  NECK 

Endothelioma. — Certain  glandular  tumors  of  the  neck  have  been 
described  as  belonging  to  the  group  of  endotheliomata  and  having  their 
origin  in  the  endothelium  lining  of  the  lymph  channels.  Clinically  they 
present  symptoms  of  a  nodular,  glandular  enlargement  definitely  cir- 
cumscribed and  usually  painless.  The  rate  of  growth  varies.  Usually 
it  is  comparatively  slow.  The  growth  arises,  as  a  rule,  in  the  upper  sub- 
sterno-mastoid  group  of  the  lymphatic  glands.  When  removed  in  the 
early  stages  it  appears  to  be  definitely  encapsulated,  and  there  is  often  a 
long  period  of  months  or  years  of  freedom  from  recurrence.  If  it  re- 
curs, the  second  growth  is  usually  at  a  lower  level  than  the  first,  arising 
apparently  in  the  supraomohyoid  gland,  and  if  it  is  allowed  to  reach 
a  large  size  projects  downward  toward  the  clavicle.  It  grows  much 
more  rapidly  than  the  first.  Removal  of  this  growth  sometimes  gives 
freedom  for  another  longer  or  shorter  period.  If  a  second  recurrence 
follows,  it  usually  makes  its  appearance  in  the  pretracheal  glands  and 
the  lower  cervical  glands  of  the  other  side  of  the  neck,  or  it  may  attack 
the  supraclavicular  glands  of  the  same  side. 

Histologically  there  is  usually  a  change  of  type,  the  growth  becoming 
more  cellular  after  each  recurrence.  These  growths  have  already  been 
referred  to  in  the  article  on  Hodgkin's  disease,  as  anomalous  malignant 
growths  having  certain  features  resembling  lymphosarcomata  and  others 
resembling  Hodgkin's  disease. 

Lipoma. — Fatty  tumors  of  the  neck  are  very  common.  They  are 
divided  into  three  varieties:  (i)  the  subcutaneous,  (2)  the  subfascial,  and 
(3)  the  diffuse. 

The  subcutaneous  form  is  of  frequent  occurrence.  The  usual 
situation  is  the  nape  of  the  neck,  where  they  often  become  very  large. 
They  are  definitely  lobulated  and  are  separated  easily  from  the  deeper 
structures. 

The  subfascial  form  is  rather  rare.  It  is  often  congenital  and  occurs 
in  young  children.  The  prolongations  of  the  tumor  burrow  under  the 
deep  cervical  fascia  and  surround  the  vessels  and  nerves  but  do  not  con- 
tract adhesions  to  them.  Consequently,  the  tumor  can  usually  be 
shelled  out  easily  without  danger.  Pressure  symptoms  have  occa- 
sionally been  noticed. 


INFLAMMATORY    AFFECTIONS    OF   THE   NECK 


391 


Diffuse  Upoma  (Fig.  188),  is  also  a  rare  disease  and  seems  to  be  con- 
fined to  middle-aged  men  who  have  otherwise  no  tendency  to  obes  y 
(Madelung).     The  disease  may  occur  in  any  part  of  the  neck     Often 
oils  of  fat  extend  round  the  neck  like  a  collar,  or  there  may  be  a  mass 


J,    Fig.  188— Diffu-t 


{Lexer-Bevan.) 


Of  fat  in  each  lateral  region  separated  by  a  median  groove.  The  ac- 
cumulation is  usually  in  the  subcutaneous  tissue  but  it  may  spread  to 
the  subfascial  space  and  surround  the  deep  vessels  and  nerves^  Unhke 
the  other  forms  of  lipoma,  there  is  an  absence  of  a  dehmte  boundary 
between  the  tumor  and  the  tissues.  , 


392  REGIONAL   SURGERY 

The  diagnosis  of  fatty  tumors  is  usually  very  easy.  The  subfascial 
forms  are  often  mistaken  for  other  conditions  and,  when  deeply  situated, 
accurate  diagnosis  may  be  impossible. 

Treatment. — The  subcutaneous  and  subfascial  tj^pes  can  usually  be 
removed  with  ease  and  safety.  In  operating  on  the  diffuse  variety,  great 
care  must  be  taken.  Total  removal  requires  an  extensive,  deep  and 
intricate  dissection  and  may  prove  a  formidable  task.  Operation  in 
successive  stages,  or  attempts  to  reduce  the  size  of  the  tumor  by  injec- 
tions of  ether,  can  hardly  be  recommended. 

CYSTS  OF  THE  NECK 

1.  Dennoid  Cysts. — Sequestration  dermoids  derived  from  infolding 
of  the  epiblastic  layer  are  found  usually  in  the  middle  line  of  the  neck 
just  above  the  sternal  notch.  As  a  rule,  they  he  between  the  sternal 
heads  of  the  sterno-mastoid  muscle  and  in  front  of  the  trachea.  They 
are  rarely  large,  but  occasionally  they  may  dip  behind  the  sternum  into 
the  upper  part  of  the  anterior  mediastinum.  They  very  seldom  cause 
any  symptoms.  Removal  is  seldom  advisable.  Tubulo-dermoids  may 
be  derived  from  either  (a)  the  branchial  clefts  or  {h)  the  thyroglossal 
duct.  The  former  are  situated  on  the  lateral  aspect  of  the  neck,  the 
latter  are  in  the  middle  Hne.     They  are  described  elsewhere. 

2.  Cystic  Hygroma  of  the  Neck. — Tumors  that  have  been  described 
from  time  to  time  under  this  name  or  that  of  "hydrocele"  of  the  neck 
have  not  always  been  of  one  kind.  Many  have  been  dermoid  cysts  and 
others  lymphangiomas.  There  seems  little  need  for  confusion  between 
hygromata  and  dermoids,  but  the  line  of  distinction  between  them  and 
l)anphangiomata  is  not  always  clear.  Dowd,  who  has  lately  written  on 
this  subject,  beheves  that  the  term  hygroma  should  be  confined  to 
"cystic  tumors  which  have  endothelial  linings  and  serous  contents  and 
which  grow  with  much  power  through  the  tissues  of  the  neck  or  down- 
ward under  the  clavicle  into  the  axilla  or  pectoral  region."  The  clin- 
ical histories  of  the  cases  vary.  In  some  instances  the  growth  is  noticed 
at  birth.  In  others,  the  neck  is  normal  at  birth  and  the  swelling  does 
not  make  its  appearance  until  after  the  lapse  of  months  or  even  years. 
The  disease  is,  however,  essentially  one  of  the  early  months  or  years  of 
childhood.  In  most  cases  the  swelling  increases  rapidly  in  size,  after 
its  first  appearance.  It  usually  starts  in  the  posterior  triangle  just  above 
the  clavicle  and  spreads  forward  under  the  sterno-mastoid  muscle  across 
the  deep  vessels  of  the  neck  which  it  covers,  or  it  may  spread  downward 
under  the  clavicle  toward  the  axilla,  or  extrapleurally  into  the  anterior 


INFLAMMATORY   AFFECTIONS    OF   THE   NECK  393 

mediastinum.  The  tumor  varies  in  size  from  that  of  a  small  orange 
to  that  of  a  cocoanut.  It  is  usually  soft  and  fluctuant.  The  contents 
are  clear,  thin  and  serous.  They  do  not  coagulate  spontaneously.  The 
rate  of  growth  is  very  slow  and  regular.  The  general  health  is  not  af- 
fected. The  final  destiny  of  the  cysts  does  not  seem  to  be  understood 
clearly.     It  would  appear  from  the  study  of  some  of  the  cases  as  if  the 


Fig.  189. — Cyst  lining  stained  with  protargol,  showing  delicate  outline  of  endothelial  cells. 

{Do'ivd,  Annals  of  Surg.) 

tendency  was  to  increase  in  size  and  to  burrow  indefinitely.  Many 
cases,  however,  reach  a  certain  size  and  then  cease  growing  and  remain 
stationary  for  many  years.  The  writer  had  the  privilege  of  seeing  in 
1896  a  grown  woman,  with  a  stationary  hygroma  of  the  neck,  who  had 
been  a  patient  of  Sir  James  Paget  when  a  child.  The  tumor  had  not 
increased  in  size  for  30  years.  A  paper  by  Dowd  (Annals  of  Surgery, 
July,  1913)  contains  perhaps  the  best  account  of  the  morbid  anatomy 
and  etiology  of  this  condition.  He  reported  four  cases,  all  occurring 
in  young  children  aged  respectively  2^^  years,  20  months,  11  months 


394  REGIONAL    SURGERY 

and  2  years.  In  each  case  the  cyst  occupied  some  part  of  the  posterior 
triangle  with  extensions,  respectively,  into  the  anterior  mediastinum 
(case  I),  under  the  clavicle  into  the  axilla  enveloping  the  pectoralis 
minor  (case  II),  up  the  neck  burrowing  under  the  trapezius  muscle 


Fig.  190. — Congenital  (?)  hydrocele  of  neck. 

(case  III),  and  over  the  deep  vessels  and  nerves  of  the  neck  (case  IV). 
The  cavities  of  the  cysts  varied  in  shape.  Among  them  were  irregular, 
unilocular  cysts  with  recesses,  two-compartment  cysts  with  an  hour- 
glass constriction,  and  typical  multilocular  cysts.     The  sac  walls  varied 


INFLAMMATORY   AFFECTIONS    OF    THE    NECK 


395 


in  thickness,  in  some  places  being  as  much  as  an  inch  thick,  in  others 
as  thin  as  2  mm.  The  walls  consisted  of  fibrous  tissue  with  a  slight 
degree  of  round-celled  infiltration.  The  inner  lining  of  the  wall  was 
found  in  two  cases  to  be  covered  by  large  pavement  epithelium  (see 
Fig.  189),  the  outlines  of  which  were  demonstrated  with  a  stain  of  pro- 
targol.  The  contents  consisted  of  a  thin  serous  fluid  of  a  yellowish 
color.     In  one  case  pus  was  found  which  contained  pneumococci  and 


Internal  Jugular  V  — 


Jugular  Approach 


SubelaTian  Approach 
Thyroeernoal  A. 


8ubol»TiA&  A. 


Jugular  Lymph  Sac 


External  Jugular  V 


Oaphalie  V 


Prlmitiva  Ulnar  Lymphatic 


Subclaviaa  ▼ 


Fig.  191. — A  reconstruction  of  the  left  jugular  Ij'mph  sac  of  an   11   mm.  cat  embryo. 
{McClure  and  Sylvester.     Dowd,  Annals  of  Surg.) 

streptococci,  a  condition  evidently  due  to  accidental  infection.  The 
case  figured  by  the  writer  occurred  in  a  young  girl  aged  15.  After 
growing  four  months  it  reached  the  size  shown  in  the  picture  (see 
Fig.  190),  no  trace  of  swelling  being  present  previously.  It  occupied  the 
whole  of  the  lower  part  of  the  right  supraclavicular  triangle,  extending 
downward  about  an  inch  below  the  clavicle,  and  forward  almost  to  the 
middle  line.  An  X-ray  picture  of  the  cyst,  after  injection  with  bismuth 
mixture,  showed  that  it  did  not  extend  downward  into  the  thorax  and 
axilla.  The  contents  were  serous  and  yellow  in  color.  At  the  operation 
it  was  found  to  extend  both  in  front  and  behind  the  sterno-mastoid  and 
to  have  intimate  connections  with  the  deep  vessels  of  the  neck.  It  was 
also  closely  connected  with  the  scalenus-anticus  muscle  and  the  cords  of 
the  brachial  plexus.     It  was  dissected  free  from  all  the  structures  with 


396  REGIONAL   SURGERY 

unusual  ease.  The  cyst  was  roughly  unilocular  with  irregular  recesses. 
The  walls  were  for  the  most  part  very  thick,  being  in  places  fully  ^-i  in. 
The  lining  was  smooth  and  shining.  The  walls  consisted  of  fibrous  tis- 
sue infiltrated  with  round  cells.  No  pavement  endothelium  could  be 
demonstrated  on  the  lining  membrane. 

The  origin  of  these  cysts  has  never  been  settled.  The  suggestion 
made  by  Dowd  that  they  arise  from  lymphatic  tissue  seems  to  be  strongly 
supported  by  the  study  of  the  lymphatics  in  the  neck  region  in  mam- 
mals (Fig.  191).  The  lymphatics  develop  as  secondary  structures 
which  are  not  primarily  connected  with  the  veins,  but  open  into  them 
later.  If  this  connection  fails,  we  may  have  a  segregation  of  lymphatic 
tissue  which  may  produce  the  cysts  under  discussion.  Another  strong 
argument  in  favor  of  this  view  lies  in  the  fact  that  the  neck  contains 
more  lymphatic  tissue  than  any  other  region  of  the  body,  the  axilla 
standing  second,  and  that  hygromata  are  most  common  in  the  neck, 
the  axilla  being  the  next  most  common  site  for  their  occurrence. 

Hemangioma  {Vascular  Navus). — Vascular  tumors  occur  in  the 
neck  quite  frequently. 

Hemangioma  Simplex. — This  form  may  be  confined  to  the  sub- 
stance of  the  true  skin,  when  it  is  invariably  formed  by  capillaries  or 
small  venules,  and  is  known  as  the  cutaneous  variety.  It  is  identical 
with  the  port-wine  stains  so  frequently  met  with  on  the  face.  It  may 
be  present  in  the  subcutaneous  tissue  at  the  same  time.  It  usually 
consists  of  collections  of  small  venules  which  are  full  of  blood,  which 
can  be  seen  shining  through  the  skin  covering  them.  Often  the  skin 
is  affected  and  nodules  or  excrescences  or  folds  like  blackberries  are 
formed.  The  cutaneous  is  often  associated  with  and  anatomically 
part  of  the  next  or  cavernous  variety. 

Hemangioma  Cavemosimi. — The  structure  of  this  variety  is  iden- 
tical with  that  of  the  corpus  cavernosum  penis.  The  blood  is  contained 
in  venous  spaces  which  connect  with  one  another.  Often  only  one  or 
two  arteries  carry  the  blood  to  the  tumor,  but  numerous  veins  may  be 
present  to  carry  it  away.  The  tumors  may  occur  in  any  part  of  the 
neck,  and  may  be  situated  either  in  the  subcutaneous  tissue  or  under 
the  deep  fascia.  As  a  rule  they  have  no  definite  outline.  When  sub- 
cutaneous, they  show  themselves  as  soft  compressible  tumors  resembling 
lipomata.  Often  their  exact  nature  is  betrayed  by  the  presence  of 
dilated  veins  in  the  skin  covering  them.  In  a  large  number  of  cases 
their  true  nature  is  unknown  until  revealed  by  operation.  This  is 
especially  true  of  those  situated  under  the  deep  fascia.     Those  deeply 


INFLAMMATORY   AFFECTIONS    OF   THE    NECK  397 

situated  often  have  very  close  relationships  with  the  deep  vessels  and 
nerves.  The  diagnosis  is  often  impossible.  Every  soft  compressible 
tumor  in  the  neck  should  be  looked  upon  with  suspicion. 

Treatment. — The  difficulties  and  dangers  of  excision  cannot  be  over- 
estimated. Even  in  the  subcutaneous  varieties  operation  may  be  te- 
dious, bloody  and  dangerous.  In  the  subfascial  forms  it  can  be  hardly 
recommended  safely.  The  cases  should  be  left  alone  unless  the  tumor  is 
increasing  rapidly.  Electrolysis  will  destroy  many  of  them  and  hold 
others  in  check.     It  is  difficult  to  employ  it  in  the  deep-seated  tumors. 

Lymphangioma  {Lymphatic  Ncevus). — The  capillary  forvis  oi  \ymph- 
angioma  are  rarely  met  with  in  the  neck.  They  are  more  common  in 
the  submucous  tissue  of  the  cheek  and  tongue. 

Lymphangioma  cavernosum  has  been  met  with  very  rarely.  It 
invariably  occurs  in  the  supraclavicular  fossa  as  a  soft  compressible 
fluctuating  tumor,  rarely  larger  than  an  orange.  It  consists  of  numer- 
ous cysts,  some  of  which  communicate  with  one  another.  The  contents 
are  thin  and  milky.  It  has  intimate  connections  with  the  jugular  and 
subclavian  veins.  It  is  probable  that  cavernous  lymphangiomata 
arise  from  the  embryonic  lymphatic  sacs  which  precede  the  formation 
of  the  permanent  lymphatics  of  the  lower  portion  of  the  neck.  Refer- 
ence has  been  made  to  this  in  the  article  on  hygroma. 

CAROTID  GLAND 

{Syn.  Glandula  Intercarotica) 

The  normal  gland  is  an  inconstant  structure,  varying  in  size  from 
4  to  7  cm.,  which  is  found  near  the  bifurcation  of  the  common  carotid 
artery  usually  more  closely  attached  to  the  internal  carotid  near  its 
origin.  It  is  roughly  oval  in  shape  and  possesses  a  well-formed  sheath 
which  penetrates  the  interior,  dividing  it  into  lobules  (Figs.  192  and 
193).  It  is  well  supplied  with  blood  derived  from  several  small  arteries 
which  arise  from  the  common  or  external  carotid  trunks.  The  lobules 
into  which  the  gland  is  divided  are  full  of  epithelial  cells  of  many  shapes. 
Many  are  round  or  oval;  others  are  spindle-shaped.  In  some  localities 
they  are  collected  into  rounded  masses  by  fibrous  septa  and  resemble  cell 
nests  or  even  glomeruli  (Zellballen).  The  blood-vessels  penetrate 
each  lobule  and  the  capillaries  are  in  intimate  relationship  with  the 
separate  cells.  The  function  of  the  gland  is  not  definitely  known. 
Luschka  looks  upon  it  as  a  nervous  structure.  Most  authors  now 
consider  it  a  vascular  organ,  although  some  of  its  features  suggest  an 
analogy  to  the  coccygeal  gland  and  adrenal  body.     The  embryology 


398 


REGIONAL    SURGERY 


Fig.  192 . — Normal  carotid  gland 
(Funke).  A,  Main  artery;  B, 
lobule;  C,  Zellballen  of  German 
writers.  (Keen  and  Funke,  Journ. 
A.M.  A.) 


of  the  gland  is  still  under  discussion. 
Its  epithelial  origin  from  the  endoderm 
of  the  third  branchial  cleft  has  been 
advanced.  Probably  the  view  of 
Paltauf  and  Katschenko  that  it  arises 
from  the  adventitia  of  the  internal  carotid 
is  more  nearly  correct.  Under  ordinary 
circumstances  the  carotid  body,  when  pres- 
ent, grows  until  puberty,  when  it  undergoes 
atrophy.  Very  rarely  it  may  continue 
to  grow  and  a  tumor  will  result.  The 
rate  of  growth  is  unusually  slow  and 
regular,  and  years  may  elapse  before  it 
becomes  as  large  as  a  walnut.  The 
tumor  never  becomes  very  large.  Half  of 
the  cases  seen  so  far  have  been  over  '30 
years  of  age,  but  most  of  them  had  been 
present  many  years.  Men  and  women 
seem  equally  liable  to  the  disease. 


ce- 


Fig.  193. — Carotid  gland  from  a  4.5  cm.  human  embryo  (Paitauf).     ci,  Internal  carotid; 
c.e.,  external  carotid.     {Keen  and  Funke,  Journ.,  A.  M.  A.) 


INFLAMMATORY   AFFECTIONS    OF   THE   NECK 


399 


Symptoms. — The  tumor  is  placed  at  the  bifurcation  of  the  carotid. 
It  is  round  Hke  a  hen  egg,  and  often  of  the  same  size.  It  is  freely  mov- 
able from  side  to  side  but  tixed  from  above  downward.  Pulsation  is 
evident,  but  it  is  clearly  transmitted  and  never  expansile.  There  is 
rarely  much  pain  in  the  tumor  or  symptoms  of  pressure  on  or  in- 
volvement of  the  nerves  of  the  neck.  In  a  few  cases  narrowing  of 
the  pupil  and  vasomotor   paralysis  have  been  noticed. 

The  diagnosis  is  ver}-  difhcult. 
Most  of  the  cases  have  been 
found  while  operating  for  the 
removal  of  glandular  or  fatty 
tumors  of  the  neck.  The 
operations  have  been  extremely 
difl&cult  and  very  bloody.  It 
is  practically  impossible  to  re- 
move the  growth  from  the 
carotids  without  splitting  it  up 
lengthwise,  and  this  procedure  is 
to  be  condemned  because  it  has 
been  followed  by  frequent  recur- 
rences. The  growth  can  be  re- 
moved in  a  satisfactory  way  only 
by  ligaturing  the  three  carotids 
and  removing  the  fork  of  the 
carotids  and  the  growth  in  one 
piece.  The  appearance  of  the 
growth  in  the  fork  of  the  carot- 
ids is  very  characteristic,  the  tumor  lying  in  it  like  a  meal  sack  thrown 
over  the  shoulder  (Fig.  194).  Dissections  of  the  specimens  removed 
show  that  it  is  impossible  to  dissect  the  tumor  from  the  blood-vessels 
without  running  serious  risks  of  leaving  some  tissue  behind  (see  Fig.  195). 

The  mortality  has  been  very  high.  Keen  collected  26  cases  oper- 
ated on  with  seven  speedy  deaths,  a  mortality  of  27  per  cent.  In  addi- 
tion to  these  deaths,  four  others  were  expected  to  die  in  a  short  time  after 
the  report.  Further,  among  the  recoveries  only  seven  appeared  to  be 
without  complications,  the  rest  sufTering,  some  from  hemiplegia  and 
asphasia,  others  from  aphonia  or  hoarseness.  Douglas  has  collected 
five  more  cases  with  one  death  and  four  recoveries,  bringing  up  the 
number  of  cases  to  31  operated  cases  with  eight  deaths,  a  mortality  of 
25  per  cent. 


Fig.  194. — Relation  of  the  tumor  to  the 
carotids  like  a  meal  sack  thrown  over  the 
shoulder.     {Keen  and  Funke,  Journ.  A.  M.  A,) 


400 


REGIONAL   SURGERY 


The  reason  of  the  high  mortahty  is  not  difficult  to  see.  In  20  of 
the  cases  all  three  carotids  were  tied,  a  procedure  that  of  itself  is  at- 
tended by  a  high  mortahty.  It  can  be  confidently  reckoned  that 
ligature  of  the  common  carotid  for  any  condition  will  be  followed  by 
a  mortahty  of  at  least  25  per  cent. 

The  macroscopic  appearances  of  these  tumors  show  them  as  nodular 
bodies  of  firm  consistence  and  of  a  reddish-brown  color.  There  is  often  a 
well-marked  capsule  which  passes  inward,  dividing  the  tumor  into  irregu- 
lar compartments.  On  section 
the  color  is  gray  interspersed 
with  dark  red  areas.  Micro- 
scopically, the  growth  conforms 
to  the  type  of  endothelioma. 
The  main  structure  under  the 
capsule  is  usually  typically  al- 
veolar, the  walls  of  the  spaces 
consisting  of  fibrous  trabeculae 
and  delicate  capillaries.  The 
cells  in  the  alveoli  vary  in  size, 
and  are  irregular  in  outline  and 
usually  possess  large  nuclei. 

Treatment. — C  onsidering 
that  tumors  of  the  carotid  body 
grow  very  slowly  and  as  a  rule 
do  not  cause  any  serious  symp- 
toms of  pressure,  and  that  the 
operation  for  their  removal 
may  require  ligature  of  the 
common  carotid  with  resection 
of  parts  of  the  internal  and  ex- 
ternal trunks,  a  procedure  followed  by  a  high  mortality  in  itself,  operation 
on  such  tumors  should  be  discountenanced  unless  serious  functional 
trouble  results  from  pressure  on  important  structures  or  rapid  growth 
of  a  mahgnant  nature  commences. 


Fig.  195. — a,  Common  carotid;  c.i.,  internal 
carotid;  c.e.,  external  carotid.  {Keen  and  Funke, 
Journ.  A.  M.  A.) 


BIBLIOGRAPHY 


Keen  and  Funks:  Journ.  Amer.  Med.  Assn.,  Aug.  18,  1906,  25. 
Da  Costa:  Annals  of  Surgery,  Vol.  XLIV,  1906. 
Douglas:  Med.  Record,  March  6,  1909. 


SECTION  XVIII 
LARYNX,  TRACHEA  AND  BRONCHI 

By 

CHEVALIER  JACKSON,  M.  D. 
Pittsburg,  Penna. 

DIRECT  LARYNGOSCOPY  AND  BRONCHOSCOPY 

Direct  laryngoscopy  and  bronchoscopy  are  procedures  using  straight 
and  rigid  tubes  which  serve  as  specula  by  drawing  out  of  the  way  tissues 
which  normally  obstruct  the  view,  or  by  dragging  the  tissues  to  be  ex- 
amined into  a  new  position  in  the  line  of  direct  vision.  Their  de- 
velopment has  revolutionized  the  surgery  of  the  larynx,  trachea  and 
bronchi.  They  are  used  through  the  mouth,  though  in  the  early  stage 
of  development  bronchoscopes  were  sometimes  passed  through  a  trache- 
otomic  wound.  Greater  skill  and  improved  instruments  have  rendered 
the  tracheotomic  route  obsolete.  Both  these  procedures  are  in  them- 
selves practically  free  from  any  vital  danger.  In  cases  of  respiratory 
obstruction  danger  may  arise  from  lack  of  promptness  in  performing 
bronchoscopy.  Tracheotomy  is  always  justifiable  for  dyspnoea,  but 
it  is  not  justifiable  for  the  purpose  of  passing  the  bronchoscope;  and, 
indeed,  in  cases  in  which  tracheotomy  had  already  been  done,  it  has 
been  found  much  more  satisfactory  to  insert  the  bronchoscope  through 
the  mouth. 

Instruments. — The  instruments  for  direct  work  upon  the  larynx, 
trachea  and  bronchi  may  be  divided  into  two  classes:  those  using  light 
reflected  down  from  above,  and  those  using  a  small  light  at  the  distal 
end  of  the  tube.  Good  work  is  done  with  both  forms  of  illumination, 
and,  doubtless,  efficiency  depends  more  upon  the  skill  and  experience 
of  the  individual  operator.  Kahler's  laryngoscope  and  bronchoscope 
(Fig.  196)  and  Briinings  (Fig.  197)  are  the  most  used  of  the  reflected- 
light  instruments.  KiUian,  who  is  the  originator  of  bronchoscopy, 
uses  the  headlamp  of  Kirstein  who  was  the  originator  of  direct  laryn- 
goscopy. Ingals,  Mosher  and  the  author  prefer  distal  illumination 
(Fig.  198).  Besides  the  tubes,  there  are  needed  various  forceps, 
sponge  carriers,  hooks  and  other  accessory  instruments. 

Direct  Laryngoscopy. — This  procedure,  called  ''direct"  laryngos- 
copy in  contradistinction  to  indirect,  or  mirror  laryngoscopy,  has 
26  401 


402 


REGIONAL   SURGERY 


entirely   superseded    the  indirect  method   for   all   except   diagnostic 
purposes. 

Anaesthesia. — For  children  no  anaesthetic,  general  or  local,  is  re- 
quired for  direct  laryngoscopy  for  either  diagnosis  or  operation  upon 
the  larynx.  For  adults,  local  anaesthesia  obtained  by  painting  the 
interior  of  the  larynx  with  a  20  per  cent,  solution  of  cocaine  will  give 


Fig.  196. — Kahler  panelectroscope.  The  tubes  used  with  this  are  similar  to  the  slid- 
ing tubes  of  Briinings.  The  rays  of  light  from  the  lamp,  h,  are  reflected  by  the  mirror,  g, 
into  the  tube,  e.  The  endoscopist's  eye  is  placed  at  the  notch  in  the  mirror,  g.  The  mir- 
ror can  be  thrown  out  of  the  way  for  the  introduction  of  instruments  by  pressure  of  the  thumb 
on  the  arm.  c. 


absolute  analgesia.  The  hypodermic  injection  of  34  gr.  of  morphine, 
about  half  an  hour  before  operation,  will  diminish  the  reflexes.  Atropin 
may  be  added  to  diminish  secretions. 

Asepsis. — The  field  cannot  be  rendered  aseptic,  but  in  view  of  the 
fact  that  we  encounter  pneumonia,  diphtheria,  syphilis,  tuberculosis 
and  various  pyogenic  infections,  and  as,  moreover,  a  patient  may  be 


LARYNX,  TRACHEA  AND  BRONCHI 


403 


more  or  less  immune  to  the  organisms  which  he  himself  harbors,  yet 
exceedingly  susceptible  to  any  nominally  identical  organisms  intro- 
duced from  without,  it  is  absolutely  essential  that  every  detail  of  aseptic 
operating-room  technique  be  carried  out  in  every  procedure.  Oral  anti- 
sepsis including  thorough  cleansing  of  the  teeth  and  gargling  and  rins- 
ing the  mouth  with  20  per  cent,  alcohol  will  practically  ehminate  septic 
risks. 

Position  of  the  Patient.— Direct  laryngoscopy  and  bronchoscopy 
in  children  are  always  done  in  the  recumbent  position.  The  same  may 
be  said  of  bronchoscopy  in  adults.     Direct  laryngoscopy  in  adults, 


Fig.    197. — Briinings'   two  illuminating  handles  for  laryngoscopes,   bronchoscopes  and 

cesophagoscopes. 

under  local  anaesthesia,  is  usually  done  in  the  sitting  position  except  in 
foreign-body  cases.  The  absolute  essential  to  all  direct  work  is  to  have 
the  head  and  neck  in  a  strongly  anterior  displacement.  This  means 
that  the  head  must  be  very  far  forward  in  the  sitting  position,  and  as 
high  as  the  table  or  higher  in  the  recumbent  position.  The  head  should 
be  extended  on  the  occipito-atloid  joint.  Flexion  of  the  head  forward 
can  be  advantageously  used  in  direct  laryngoscopy  as  demonstrated  by 
Mosher  and  Johnston.  Flexion,  however,  is  not  suited  to  bronchos- 
copy. When  extension  is  referred  to,  it  means  strictly  extension  of  the 
occipito-atloid  joint  and  not  extension  of  the  cervical  vertebra,  which 
should  be  on  an  inclined  plane  forward.     This  forward  position  must 


404 


REGIONAL   SURGERY 


be  maintained  by  the  assistant  who  holds  the  head,  and  at  the  same 
time  prevents  it  from  rotating. 

Technique. — Exposure  of  the  glottis  with  a  straight  endoscopic  tube 
requires  the  displacement  forward  of  the  tongue  and  all  of  the  tissues 
attached  to  the  hyoid  bone.  After  skill  is  acquired,  the  amount  of 
pressure  necessary  to  produce  displacement  can  be  very  much  dimin- 


FiG.  198. — Chevalier  Jackson's  instruments  for  direct  laryngoscopy,  bronchoscopy 
and  oesophagoscopy:  A,  bronchoscope;  B,  olive  bougie  for  oesophagoscopic  bouginage; 
C,  sponge-carrier  for  sponging  the  field  and  obtaining  specimens  of  secretion  from  the 
bronchi;  D,  forceps  for  removing  foreign  bodies;  E,  forceps  for  removing  tissue;  F,  direct 
laryngoscope,  called  also  slide-speculum  and  laryngeal  speculum;  G,  bite-block;  H,  oesoph- 
agoscope  with  tubing  (/)  leading  to  aspirator  J,K  for  removal  of  secretions  without 
interrupting  work.  The  tubing,  L,  is  connected  with  positive-pressure  side  of  the  syringe, 
K,  for  use  when  needed  to  blow  out  obstructions,  such  as  clots  of  pus,  food,  etc.,  that  have 
been  aspirated  into  the  drainage  canal  of  the  cesophagoscope.  At  M  is  shown  a  gastro- 
scope.     In  almost  all  cases  the  cesophagoscope  in  found  to  be  long  enough  for  gastroscopy. 

ished  by  using  a  narrow  tube  at  the  side  of  the  tongue,  but  in  this 
position  the  landmarks  are  very  much  less  easily  recognized  and  the 
less  skilful  will  be  bewildered  unless  they  pass  the  instrument  over 
the  dorsum  of  the  tongue.  Glottic  exposure  by  the  latter  route  is 
divided  into  two  stages. 

First  Stage. — The  operator  holds  the  laryngoscope  in  his  left  hand 


LARYNX,  TRACHEA  AND  BRONCHI 


405 


(Fig.  200)  while  with  his  right  index  finger  he  raises  the  patient's  upper 
lip  so  that  it  cannot  be  pinched  between  the  laryngoscope  and  the  teeth. 
The  distal  end  of  the  laryngoscope  is  passed  backward  over  the  median 
line  of  the  dorsum  of  the  tongue,  and,  depressing  the  tongue,  in  the 
direction  of  the  dart  at  A,  Fig.  201,  the  upper  edge  of  the  epiglottis  will 


\ 

f 

W 

\V>:0-^^r            ; 

:       .- r. -.-.-.-::.-- .■::■:.-   j^ 

Fig.  199.  Laryngoscope  with  heart-shaped  lumen  devised  bj'  the  author  especially 
for  direct  laryngeal  operating,  rendering  easy  the  exposure  of  the  anterior  laryngeal 
comnaissure  in  everj'  case.     It  is  not  adapted  to  the  passage  of  bronchoscopes. 

come  into  view.  The  identification  of  the  epiglottis  must  never  be 
slighted,  and  great  care  must  be  taken  not  to  go  beyond  it  without 
identifying  it. 

Second  Stage. — Having  identified  the  epiglottis  the  next  step  is  to 
pass  the  spatular  end  of  the  speculum  posteriorly  to  the  epiglottis 


Fig.  200. — Direct  laryngoscopy.     First  stage.     (Jackson.) 

or  a  distance  of  about  i  cm.  or  1.5  cm.  (slightly  less  than  i  cm.  in  a 
child).  These  measurements  are  only  approximate;  experience  must 
be  relied  upon  for  proper  gauging  of  the  depth. 

Third  Stage. — Without  permitting  the  laryngoscope  to  go  deeper, 
the  larynx  is  exposed  by  a  forward  movement  of  the  spatular  end  of 


4o6 


REGIONAL   SURGERY 


Fig.  20 1. — Schema  showing  the  first  and  third  stages  in  exposing  the  larjmx  in  direct 
laryngoscopy.  At  the  left  the  tongue  is  being  depressed  as  indicated  by  the  dart,  causing 
the  epiglottis  to  project  into  the  line  of  vision  as  shown  in  the  lower  illustration.  The 
laryngoscope  is  inserted  deeper  constituting  the  second  stage.  At  the  right  is  shown  the 
third  stage,  the  drawing  forward  of  the  epiglottis  and  all  of  the  tissues  attached  to  the  hyoid 
bone  witi  the  tip  of  spatular  end,  thus  exposing  the  spasmodically  closed  larynx.  At  the 
next  inspiration  the  larynx  wUl  open,  exposing  the  cords  and  glottis.     (Jackson.) 


Fig.  202. — Showing  the  author's  position  of  the  operator,  patient  and  assistant  for 
direct  laryngoscopy  on  adult  patients  under  local  anaesthesia.  The  sitting  position  of 
the  operator  renders  laryngeal  exposure  easy  for  patient  and  operator;  whereas  the  usual 
standing  position  of  the  operator  throws  the  patient  into  a  posture  that  renders  laryngeal 
exposure  difficult  as  well  as  throwing  the  trachea  out  of  line.  The  illustration  shows  the 
third  stage,  with  full  exposure  of  the  larynx.     (Jackson.) 


LARYNX,  TRACHEA  AND  BRONCHI 


407 


the  laryngoscope  in  the  direction  of  the  dart  at  B,  Fig.  201.  On  the 
proper  execution  of  this  movement  depends  the  knack  of  success.  It 
is,  perhaps,  best  described  as  an  effort  to  pull  the  epiglottis  and  hyoid 
bone  downward,  outward  and  forward  toward  the  operator  with  the 
tip  of  the  spatular  end.  The  patient's  whole  head  should  be  pulled 
forward  by  the  power  exerted.  Great  care  must  be  taken  not  to  fall 
into  the  error  of  using  the  upper  teeth  as  a  fulcrum  for  the  prying  for- 
ward of  the  anterior  pharyngeal  tissues.  Such  a  use  of  leverage  will 
defeat  its  own  object.  When  first  seen,  the  glottic  spasm  is  very  likely 
to  have  closed  the  larynx  and  a  deep  inspiration  must  be  waited  for, 


Fig.  203. — Introducing  forceps  into  bronchoscope  for  seizing  foreign  body  in  the  bronchus. 

(Jackson.) 

the  patient  being  encouraged  and  pacified  if  alarmed;  he  should  be 
told  to  take  a  deep  breath,  and  to  continue  deep  breathing. 

The  laryngoscopic  picture  differs  very  much  from  that  obtained  with 
the  mirror  because  of  the  difference  in  the  point  of  view  and  also  because 
the  larynx  is  shown  at  its  true  depth,  whereas  with  the  mirror  there  is  a 
foreshortening  illusion. 

Under  general  anaesthesia  the  amount  of  pressure  needed  for  dis- 
placement of  the  tissues  obstructing  the  view  is  very  slight  because  of 
the  relaxation.  Under  local  anaesthesia  the  necessary  pressure  can  be 
very  much  diminished  by  using  a  small  tube  and  working  at  the  side 
of  the  tongue.     In  doing  this  it  is  very  necessary  to  remember  the  dis- 


4o8 


REGIONAL   SURGERY 


tortion  produced  by  the  angle  of  approach,  and  also  to  prevent  the  error 
of  mistaking  the  aryepiglottic  fold  for  the  epiglottis  itself.  This  lateral 
route  presents  great  advantages  in  operating  on  growths  located  at  one 
side  of  the  larynx,  as  shown  in  Fig.  217,  the  tube  being  inserted  from 
the  side  opposite  to  that  on  which  the  growth  is  located.  Except  for 
exposure  of  the  opposite  side,  the  tube  is  nearly  vertical,  and  not  at 
the  angle  shown.  The  best  instrument  for  direct  endolaryngeal  oper- 
ating by  the  laterolingual  route  is  that  shown  in  Fig.  199.  It  may 
be  used  on  either  side  of  the  tongue,  but,  usually,  the  right  side  is 
preferred  for  the  recumbent  patient,  the  left  side  for  the  sitting 
patient. 

Direct  Laryngoscopy  for  the  Introduction  of  InsuflElation  Anaesthesia 
Tubes. — The  patient  is  necessarily  in   the  recumbent  position  and 


Fig.  204. 


Fig.  205. 


Fig.  206. 


Fig.  204. — Photograph  of  patient  with  head  upon  a  pillow,  the  head  flexed.  In  this 
position  it  is  easy  to  examine  the  larynx  with  the  laryngoscope  for  diagnosis,  but  the  larynx 
will  not  be  exposed  in  a  line  with  the  tracheal  axis  so  that  this  position  is  not  adapted  to 
the  passing  of  tubes  through  the  laryngoscope. 

Fig.  205. — The  pillow  is  removed,  the  head  is  flat  on  the  table  and  the  anaesthetist 
is  beginning  to  force  the  head  into  the  extended  position.  The  thumbs  are  on  the  forehead 
and  the  fingers  are  at  the  side  of  the  head.  The  direction  of  motion  is  shown  by  the  dart. 
{Jackson.) 

Fig.  206. — The  anaesthetist  is  lifting  with  the  tip  of  the  laryngoscope  in  the  direction 
of  the  dart.  The  laryngoscope  is  always  held  in  the  left  hand.  The  right  hand,  of 
which  the  index  has  been  protecting  the  upper  lip,  has  now  received  the  catheter  from 
the  nurse. 


should  be  fully  relaxed  by  the  preliminary  administration  of  the 
anaesthetic  by  inhalation  in  the  ordinary  way.  With  practice  the  larynx 
of  any  patient  can  be  exposed  without  any  anaesthetic,  general  or  local, 
but  for  the  introduction  of  insufflation  tubes  the  patient  is  to  be 
anaesthetized  anyway  and  the  procedure  is  greatly  facilitated  by  full 


LARYNX,  TRACHEA  AND  BRONCHI 


409 


relaxation  of  general  anaesthesia.  The  patient's  head  should  rest  upon 
the  table.  The  anaesthetist 
should  cover  the  head  with  a 
towel  and  produce  forcible  ex- 
tension by  placing  his  two  thumbs 
on  the  forehead  with  his  fingers 
under  the  occiput  as  shown  in 
Fig.  205.  The  motion  is  to  press 
the  forehead  downward  toward 
the  patient's  feet  and  thus  to 
throw  the  chin  and  larynx  high. 
The  head  should  be  maintained 
in  this  position  while  the  an- 
aesthetist introduces  the  laryngo- 
scope and,  by  a  strong  lifting 
motion  with  the  tip  of  the  spatular 
end  of  the  speculum,  tries  to  lift 
the  patient's  neck  off  the  table 
with  the  spatula  tip  as  soon  as 
the  tip  is  placed  below  the  epi- 
glottis, which  in  all  cases  should 
be  first  identified. 

Introduction  of  the  Broncho- 
scope.— The  introduction  of  the 
bronchoscope  is  easy  to  those  who 
have  mastered  glottic  exposure 
with  the  direct  laryngoscope,  and 
no  one  should  attempt  bronchos- 
copy until  he  can  promptly  ex- 
pose the  larynx  with  the  laryngo- 
scope held  in  the  left  hand.  The 
bronchoscope  is  inserted  (Fig.  207) 
with   the  right   hand.     Each   in- 


FiG.    207. — Schema      illustrating    oral 
bronchoscopy.     The  portion   of  the  table 
here  shown  under  the  head  is,   in   actual     1 
work,  dropped  all  the  way  down  perpen- 
dicularly.    It  appears  in  these  drawings  as  a  dotted  line  to  emphasize  the  fact  that> 
the  head  must  be  above  the  level  of  the  table  during  introduction  of  the  bronchoscope 
into  the  trachea.    .4,  exposure  of  larynx.    5,  bronchoscope  introduced.    C,  slide  removed. 
D,  laryngoscope  removed  leaving  bronchoscope  alone  in  position.     {Jackson.) 


4IO  REGIONAL    SURGERY 

strument  is  lighted  by  its  own  lamp  there  being  two  separate 
cords  and  circuits  from  the  battery.  The  glottis  being  exposed  with 
the  left  hand,  the  bronchoscope  is  taken  in  the  right  hand,  the  handle 
being  horizontally  out  to  the  right.  This  brings  the  lip  of  the  broncho- 
scope to  the  right  of  the  glottic  chink  as  shown  in  the  circle.  Waiting 
for  an  inspiratory  abducting  excursion  of  the  vocal  cord,  the  broncho- 
scopic  lip  is  moved  slightly  to  the  left  and  slipped  through  the  chink. 
The  laryngoscope,  which  is  necessarily  constructed  heavily  for  displace- 
ment, is  now  removed,  leaving  the  light  and  delicate  bronchoscopic  tube 
for  the  work  within  the  trachea  and  bronchi. 

In  passing  down  the  trachea  the  bronchoscope  ordinarily  will  find 
its  way  into  the  right  bronchus,  the  orifice  of  the  left  bronchus  being 
missed  unless  watched  for.  When  it  is  desired  to  enter  the  left 
bronchus,  the  patient's  head  should  be  moved  to  the  right  and  the 
handle  of  the  bronchoscope  rotated  so  as  to  stand  out  horizontally  to 
the  left  by  which  means  the  lip  of  the  bonchoscope  will  have  a  tendency 
to  enter  the  left  bronchus  and  the  carina  at  the  bifurcation  is  thus 
readily  identified.  This  identification  must  be  always  assured  before 
going  deeper.  On  the  left  side  the  upper  lobe  bronchus  is  the  only  very 
large  branch  given  off,  all  below  that  being  the  inferior  lobe  bronchus. 
On  the  right  side  the  upper  lobe  bronchus  is  also  a  large  branch.  Just 
below  it  and  passing  off  anteriorly  will  be  found  the  middle  lobe 
bronchus,  all  below  that  being  the  inferior  lobe  bronchus  which  gives 
off  dorsal  and  ventral  branches. 

FOREIGN  BODIES  IN  THE  LARYNX 

The  symptoms  produced  by  lodgment  of  a  foreign  body  in  the  larynx 
depend  largely  upon  its  size.  Small  foreign  bodies  usually  cause  cough- 
ing which  quickly  subsides,  and  thereafter  there  may  be  no  symptoms 
for  a  number  of  days  until  the  inflammatory  reaction  produces  all  the 
symptoms  of  laryngitis.  In  children  all  of  the  symptoms  of  diphtheria 
may  be  present  and  a  number  of  such  cases  have  come  to  the  author 
where  antitoxin  has  been  given,  the  child  having  aspirated  the  foreign 
body  unknown  to  the  parents.  All  cases  of  horaseness  in  children 
should  be  examined  by  the  direct  laryngoscope.  In  adults  a  sensation 
of  pricking  and  desire  to  cough  may  be  constantly  present.  Very  large 
foreign  bodies  produce  cyanosis  and  all  the  alarming  symptoms 
associated  with  a  fight  for  air. 

Removal  of  Foreign  Bodies  from  the  Larynx. — A  patient  supposed 
to  have  a  foreign  boyd  in  the  larynx  should  not  be  allowed  to  raise 


LARYNX,  TRACHEA  AND  BROXCHI  4II 

his  head  lest  the  intruder  be  aspirated  into  the  deeper  air  passages. 
A  large  proportion  of  the  foreign  Uodies  in  the  bronchi  were  at  an  earlier 
stage  known  to  be  in  the  larynx.  Indirect  laryngoscopy  may  be  used 
if*desired  for  the  examination  of  adults,  but  this  must  be  done  in  the 
recumbent  position.  In  children  indirect  laryngoscopy  is  impossible 
and  the  direct  method  only  is  available.  In  either  adults  or  children 
the  head  should  be  lowered  on  an  inchned  table  so  that  if  the  intruder 
is  dislodged  it  cannot  be  aspirated  and  gravity  will  work  in  favor  of 
removal  rather  than  in  favor  of  aspiration.  The  long  alligator  forceps 
ofJMosher  should  be  used  through  the  laryngoscope. 

Direct  laryngoscopy  renders  removal  so  quick  and  so  certain  that 
tracheotomy  is  no  longer  thought  justifiable  for  the  removal  of  a  foreign 
body  if  direct  laryngoscopic  instruments  are  available.  If  the  foreign 
body  is  threatening  asphyxia,  the  cardinal  rule  of  doing  a  tracheotomy 
early  rather  than  later  should  be  followed. 

FOREIGN  BODIES  IN  THE  TRACHEA  AND  BRONCHI 

The  first  symptom  of  a  foreign  body  having  entered  the  trachea  is 
cough,  usually  violent.  Sometimes  there  is  also  a  blood-streaked  ex- 
pectoration. In  almost  all  cases  after  the  first  few  days  all  symptoms 
subside  and  the  patient  feels  that  he  must  have  been  mistaken  in  regard 
to  the  entrance  of  the  foreign  body.  Later,  however,  inevitably,  a 
cough,  at  first  sHght,  will  set  in  and  the  patient  will  gradually  lose 
health  and  strength  until  ultimately  at  the  end  of  a  year  or  more  the 
patient  will  die  of  all  the  symptoms  of  tuberculosis  or  of  lung  abscess. 
Round  smooth  foreign  bodies  are  sometimes  coughed  out,  but  heavy 
bodies  rarely  are,  and  pointed  bodies  such  as  pins  and  tacks  never  are. 
Pins,  needles  and  similar  bodies  have  a  ratchet-like  action,  the  point 
preventing  return  while  nothing  resists  the  advance  until  the  foreign 
body  has  reached  the  smallest  bronchus  it  can  enter. 

The  physical  signs  associated  with  foreign  body  are  very  misleading 
and  are  never  of  value  taken  negatively.  If  one  bronchus  is  completely 
obstructed  there  will  naturally  be  the  physical  signs  of  loss  of  air  on  the 
corresponding  side,  but  if  air  can  pass  the  intruder  the  symptoms  are  apt 
to  be  bilateral  because  the  physical  signs  in  such  a  case  are  produced 
by  secretions  which  get  into  the  uninvaded  as  well  as  the  invad  deside. 
Intermittent  dyspnea  may  be  due  to  a  valve-like  action  of  a  flat 
foreign  body.  All  cases  with  a  foreign  body  history  should  be  sent  to 
the  rontgenologist  even  if  the  foreign  body  be  one  not  opaque  to  the 
ray,  because  the  intruder  of  which  we  get  a  history  may  not  be  the  same 


412 


REGIONAL   SURGERY 


as  the  one  actually  present,  as,  for  instance,  when  a  pin  from  the  cook's 
clothing,  getting  into  the  food,  is  mistaken  for  a  bone.  If  the  radio- 
graph show  a  foreign  body,  bronchoscopic  removal  is  facihtated,  but 
if  the  radiograph  be  negative,  a  bronchoscopy  should  be  done  anyway. 
Localization  is  greatly  aided  by  the  author's  positive  films  of  the 
tracheobronchial  tree  (Fig.  208). 


Fig.  208. — Chevalier  Jackson's  transparent  positive  films  of  the  tracheobronchial 
tree.  When  placed  over  the  negative  of  the  patient  the  foreign  body,  (strengthened  with 
ink  if  necessary)  shows  through,  revealing  its  location  in  the  tree.  The  lines  A ,  representing 
the  pleural  dome  and  B.  the  diaphragmatic  dome  are  used,  instead  of  bony  landmarks. 
(Jackson.) 

Bronchoscopy  is  indicated  in  every  case  of  foreign  body  in  the 
trachea  and  bronchi,  and  there  are  no  contraindications.  Should 
bronchoscopy  fail,  thoracotomy  is  indicated  because  the  intruder  will 
ultimately  prove  fatal  and  the  chances  of  its  being  coughed  up  are  so 
remote  that  it  is  unwise  to  take  the  risks  involved  in  the  secondary  proc- 
esses. There  are,  however,  a  number  of  cases  in  which  foreign  bodies 
have  been  present  in  the  lungs  for  prolonged  periods  without  being 
fatal  though  the  patients  were  all  in  extremis  from  the  prolonged  sup- 
puration. The  author  had  one  case  in  which  a  tack  was  present  for 
two  years,  another  in  which  a  lead  collar  button  was  present  for  10 
years,  another  in  which  a  price  tag  fastener  was  present  for  eight  years, 
and  one  case  in  which  a  glass  collar  button  had  been  in  the  lung  for 


LARYNX,  TRACHEA  AND  BRONCHI  413 

26  years.  In  all  of  these  cases  the  intruder  was  removed  by  bronchos- 
copy through  the  mouth  and  the  patients  all  recovered  health.  But 
the  statistics  collected  in  the  prebronchoscopic  days  show  clearly  that 
foreign  bodies  are  almost  always  ultimately  fatal  and  usually  within  a 
period  of  from  one  and  one-half  to  two  years. 

Bronchoscopy  for  Foreign  Bodies. — Of  the  author's  last  182  consecu- 
tive cases  the  foreign  body  was  removed  in  177.  Of  the  five  failures 
to  remove  foreign  bodies  known  to  be  present,  all  were  failures  to  find 
a  small  foreign  body  that  was  in  a  small  branch  bronchus  close  to  the 
periphery  of  the  lung.  Of  the  182  cases  there  was  a  total  of  three  deaths 
(1.7  per  cent.)  from  any  cause  whatever  within  one  month,  though  a 
few  cases  could  not  be  followed  this  long.  None  of  the  fatalities  was 
due  to  the  procedure  of  bronchoscopy  itself.  All  of  the  bronchoscopies 
were  done  bloodlessly  through  the  mouth.  The  phenomenal  success 
of  bronchoscopy  renders  any  other  procedure  inadvisable  until  bronchos- 
copy has  failed. 


Fig.  209. — The  author's  safety-pin  closer.  The  closer  is  passed  under  ocular  control 
until  the  ring,  R,  is  below  the  pin.  The  ring  is  then  erected  to  the  position  shown  dotted 
at  M,  by  moving  the  handle,  H,  downward  to  L  and  locking  it  there  with  the  latch  Z. 
The  fork,  A,  is  then  inserted  and,  engaging  the  pin  at  the  spring  loop,  K,  the  pin  is  pushed 
into  the  ring,  thus  closing  the  pin.     (Jackson.) 

The  method  of  introduction  of  the  bronchoscope  is  elsewhere  herein 
given.  Having  found  the  intruder  by  means  of  the  bronchoscope  the 
mechanical  problem  of  its  location  must  be  studied  and  removal  de- 
vised on  a  plan  that  will  render  injury  to  the  bronchial  tissues  impossible. 
Pointed  objects  such  as  pins  must  have  the  point  dislodged  and  brought 
within  the  tube-mouth  before  any  attempt  at  extraction  is  made. 
Dislodgement  is  usually  accomplished  by  pushing  downward  with 
forceps,  the  lower  extremity  of  the  foreign  body  being  guided  into  a 
branch  bronchus.  Safety  pins  should  be  closed  before  removal,  with 
special  instruments  that  have  been  devised  for  the  purpose  (Fig.  209). 
A  very  ingenious  closer  on  the  tube-mouth  has  been  devised  by  Mosher, 
who  also  devised  the  first  ring  form  of  closer.  Transfixed  objects  must 
have  one  point  depressed  and  then  have  the  other  point  disengaged  by 
counterpressure  with  the  lip  of  the  bronchoscope  while  gentle  traction 
is  made  with  the  forceps.     Special  rotation  forceps  have  been  devised 


414 


REGIONAL    SURGERY 


Fig.  2IO. — Radiographs,  lateral  and  anteroposterior  showing  staple  in  a  small  posterior 
branch  of  the  inferior  lobe  bronchus  of  a  man  aged  35  years.  Staple  was  turned 
and  removed  bloodlessly  through  the  mouth  by  bronchoscopy,  under  local  anaesthesia. 
(Author's  case.     Radiographs  made  by  Johnston  and  Grier.) 


LARYNX,  TRACHEA  AND  BRONCHI 


415 


by  the  author  for  this  purpose.  Under  no  circumstances  should  a  body 
be  grasped  when  first  seen  and  violently  pulled  upon,  as  fatal  trauma 
may  result.  Bodies  too  large  to  be  removed  through  the 
bronchoscope  are  removed  by  withdrawing  the  forceps, 
bronchoscope  and  foreign  body  all  out  together;  but  before 
doing  so  it  is  necessary  to  be  certain  that  there  are  no 
projecting  points  in  such  position  as  to  injure  the  tracheo- 
bronchial wall.  Double-pointed  tacks  and  staples,  when 
lodged  point  upward,  as  they  usually  are,  must  never  be  Fence  staple 
pulled  upon  as  fatal  trauma   would   be   certainly   inflicted  removed  by 

'^  ^  _  _  ^_  -^  broncho- 

by  the  points  ripping  into  the  bronchial  wall.  They  s  c  o  p  y 
must  be  turned  before  removal.  At  the  bifurcation  is  the  ^outh  from 
widest  place.     In  the  case  shown  in  Fig.  210  the  staple  was  the  location 

11T  •  ri  1-11  shownin 

4  m.  below  the  bifurcation  of  the  trachea  and  tightly  wedged  Fig.g2io. 


Fig.  212. — Dental  instrument  (broach)  removed  bloodlcssly  through  the  mouth  by 
bronchoscop}'  under  local  anaesthesia  from  the  right  lung  of  a  man  aged  ,53  years. 
See  radiograph,  Fig.  213.     (Author's  case.     Radiograph  made  by  Johnston  and  Grier.) 

in  a  small  bronchus.     The  author  succeeded  in  getting  the  two  points 
into  a  pair  of  suitably  spaced  branch  bronchial  orifices,   thus  permit- 


4i6 


REGIONAL   SURGERY 


ting  rotation,  and  withdrawal  with  turning  forceps  grasping  the  round 
end,  the  points  trailing  harmlessly  behind.  Extreme  depth  of  lodg- 
ment, as  in  the  case  illustrated  in  Fig.  112  requires  a  small  bron- 
choscope because  of  the  small  size  of  the  invaded  bronchus. 

For  further  detailed  consideration  of  the  mechanical  problems  con- 
nected with  the  bronchoscopic  extraction  of  the  manifold  forms  of 
foreign  bodies,  the  reader  is  referred  to  the  book,  "Peroral  Endoscopy 
and  Laryngeal  Surgery,"  by  Chevalier  Jackson. 

The  fluoroscope  has  occasionally  been  used  for  guiding  the  forceps 
in  the  removal  of  a  bronchially  lodged  foreign  body.  Six  deaths  have 
been  reported  from  injury  thus  inflicted.  It  can  be  successful  only  in 
cases  that  would  be  most  easily  removed  by  ordinary  bronchoscopy. 


i 


Fig.  213.  Fig.  214. 

Fig.  213. — Radiograph  of  a  dental  instrument  (broach)  in  a  minute  posterior  branch 
of  the  right  inferior  lobe  bronchus  of  a  man  53  years  of  age.  Removed  bloodlessly  through 
the  mouth  by  bronchoscopy,     (Author's  case.) 

Fig.  214. — The  author's  flexible-ended  upper-lobe  bronchus  forceps  for  reaching 
"around  the  corner."  The  forceps  are  shown  grasping  a  pin  (A)  in  an  ascending  branch 
of  the  upper  lobe  bronchus  (UL).  5,  stem-bronchus;  LB,  left  main  bronchusj  T,  trachea. 
(Jackson.) 

There  is  a  class  of  cases,  however,  in  which  the  fluoroscope  can  be  of 
great  aid.  In  the  cases  of  small  foreign  bodies  far  down  and  far  out 
at  the  periphery  in  a  minute  bronchus  too  small  to  enter  with  the 
bronchoscope,  the  number  of  bronchi  to  be  searched  can  be  limited  to 
a  few  by  the  advice  given  by  the  fluoroscopist  who  works  with  a  com- 
bined vertical  and  horizontal  fluoroscopic  screen,  devised  for  the  author 
by  Dr.  George  W.  Grier.  In  using  it  the  bronchoscopist  works  as  usual 
through  his  bronchoscope  and  consequently  is  certain  of  doing  no  harm 
because  he  can  see  the  action  of  his  forceps  and  he  is  guided  by  directions 
such  as  "anteriorly,  posteriorly  and  laterally."  Thus  he  quickly 
locates  the  particular  minute  bronchus  invaded  and  can  explore  it 
carefully  with  probe  and  forceps.     This  method  is  also  useful  for  foreign 


LARYNX,  TRACHEA  AND  BRONCHI  417 

bodies  "around  the  corner"  in  the  upper  lobe  bronchus,  using  the 
author's  special  upper-lobe-bronchus  forceps  (Fig.  214). 

Magnets  have  been  used  through  the  bronchoscope  chiefly  in  two 
forms:  one,  a  long  magnet  of  small  diameter,  inserted  through  the  bron- 
choscope; and  the  other  a  steel  rod,  introduced  through  the  broncho- 
scope and  energized  by  a  very  powerful  magnet  such  as  used  by  the 
ophthalmologists.  The  chief  reason  for  failure  is,  as  shown  by  the 
author,  that  the  foreign  body  is  seldom  free  to  move,  and  the  attraction 
of  the  magnet  for  the  foreign  body  is  no  greater  than  the  foreign  body 
for  the  magnet.  For  this  reason  a  very  small  body,  which  is  the  only 
kind  that  has  not  been  found  at  bronchoscopy,  is  acted  upon  but  very 
feebly.  A  foreign  body  as  large  as  a  railroad  spike  could  be  pulled 
out  through  the  chest  wall.  Necessarily  only  foreign  bodies  composed 
partly  or  wholly  of  iron  or  steel  are  susceptible  to  magnetism. 

INJURIES  OF  THE  LARYNX 

The  larynx  may  be  injured  internally  by  foreign  bodies,  or  by  the 
finger  in  attempts  to  recover  a  foreign  body,  or  by  unskilful  instru- 
mentation such  as  in  the  effort  to  pass  oesophageal  bougies,  probangs, 
oesophagoscopes,  bronchoscopes,  etc.  Before  the  days  of  oesophagos- 
copy  a  common  form  of  injury  was  with  the  Graefe  basket  in  the  effort 
to  pass  it  into  the  oesophagus  for  a  foreign  body.  On  withdrawal,  it 
would  denude  the  cricoid  cartilage,  or  even  eviscerate  the  larynx,  if, 
as  sometimes  happened,  it  had  entered  the  larynx  instead  of  the 
trachea.  External  forms  of  injury  are  caused  by  hanging,  cut  throat, 
garrotting  and  by  falls  on  the  neck.  Suicidal  attempts  are  usually  too 
high  to  sever  very  large  vessels.  Stab  wounds  may  be  fatal  from 
hemorrhage.  In  either  case  the  chief  dangers  are  from  hemorrhage, 
suffocation  by  aspirated  blood,  and  entrance  of  air  into  veins.  The 
secondary  dangers  are  from  acute  oedematous  stenosis  of  the  air  pas- 
sages, sepsis,  celluHtis  and  perichondritis  with  chondrial  necrosis.  Ulti- 
mately, injury  to  the  larynx  is  very  prone  to  result  in  stenosis  from 
cicatricial  contraction  or  from  loss  of  cartilage  upon  whose  stiffness  the 
open  lumen  depends.  Cartilage  about  the  air  passages,  in  healing,  is 
always  associated  with  exuberant  fungating  granulations  which  produce 
stenosis,  retard  healing  and  build  up  a  mass  of  cicatricial  tissue. 

Treatment. — After  the  arrest  of  hemorrhage,  the  first  step  should 

always  be  to  examine  the  larynx  by  direct  or  indirect  laryngoscopy  in 

order  to  ascertain  the  presence  of  oedema.     If  present,   tracheotomy 

should  be  done  early  rather  than  late.     The  tracheotomy  should  be 

37 


41 8  REGIONAL   SURGERY 

low.  In  external  wounds  of  the  larynx,  hemorrhage  should  be  arrested, 
clots  removed  and  the  parts  cleansed  with  an  antiseptic  solution,  taking 
great  care  to  remove  particles  of  clothing  or  other  foreign  matter. 
The  deeper  structures  should  be  closed  with  catgut,  silver  wire  or  tendon 
sutures,  silkworm-gut  being  used  for  the  superficial  stitches.  Quite 
often,  in  cut-throat  wounds  especially,  the  whole  wound  will  break 
down  and  suppurate,  the  stitches  sloughing  loose.  In  this  case  it  is 
better  to  pack  the  wound,  and  re-dress  every  hour  or  two.  It  will 
usually  be  necessary  in  these  cases  to  insert  an  intubation  tube  of  large 
size  in  order  to  prevent  stenosis  from  malposition  of  the  cartilages  and 
cicatricial  contraction.  The  intubation  tube  should  be  removed  at 
least  every  other  day  for  cleansing  and  replacement.  It  should  be  in- 
troduced through  the  mouth  as  mentioned  under  laryngostomy. 
Feeding  should  be  by  soft  rubber  tube  for  the  first  week  because  food 
is  very  apt  to  get  into  the  larynx  and  escape  into  the  wound.  If  this 
occur,  in  spite  of  precautions,  it  is  necessary  to  change  the  dressings 
at  once  after  each  feeding. 

Fractures  of  the  Lar3nix. — Fractures  of  the  laryngeal  cartilages  may 
occur  from  any  form  of  external  violence.  Fracture  of  the  hyoid  bone 
may  be  associated.  Fractures  occur  only  in  adults,  and  especially  after 
partial  ossification  of  the  cartilages.  It  is  usually  the  thyroid  cartilage 
that  is  involved.  The  external  perichondrium  may  or  may  not  be 
ruptured.  The  mucous  membrane  of  the  interior  is  rarely  torn.  The 
local  symptoms  are  pain,  tenderness  and  swelling  with  bloody  expec- 
toration if  the  mucous  membrane  has  been  torn.  If  the  external  peri- 
chondrium is  ruptured,  emphysema  of  the  neck  follows  and  extends  to 
other  regions.  Laryngoscopic  examination  may  show  spots  of  ecchy- 
mosis  and  oedema.  A  positive  diagnosis  can  be  made  only  by  the  elici- 
tation  of  crepitus  or  by  a  radiograph.  Negative  results  of  these  must 
not  be  given  too  much  weight.  The  prognosis  is  always  serious, 
though  doubtless  it  would  be  very  much  less  so  if  tracheotomy  were 
always  done  as  a  precautionary  measure.  Most  of  the  deaths  have 
been  from  the  sudden  onset  of  obstructive  dyspnoea,  from  oedema  or 
displacement  of  a  portion  of  cartilage,  the  other  and  rarer  causes  being 
shock,  emphysema  of  the  mediastinum,  bronchopneumonia,  and 
septicemia.  Stenosis  from  deformity  or  cicatricial  contraction  is  a 
frequent  result. 

The  best  treatment  is  tracheotomy  and,  in  the  author's  opinion,  this 
should  be  done  in  every  case  in  which  a  diagnosis  of  fracture  can  be 
made,  regardless  of  whether  obstructive  dyspnoea  is  present  or  not,  be- 


LARYNX,  TRACHEA  AND  BRONCHI 


419 


cause  of  the  frequently  sudden  onset  of  asphyxia.  Intubation  is  un- 
reUable  though  it  will  probably  be  required  later  after  tracheotomy  to 
prevent  stenosis  of  the  larynx  from  misplaced  cartilages.  This  use  of 
an  intubation  tube  as  an  internal  splint  is  better  at  this  acute  stage  than 
the  operation  of  laryngostomy  because  the  incision  required  in  laryn- 
gostomy  or  thyrotomy  may  make  islands  of  cartilage  out  of  the  frag- 
ments with  consequent  increased  tendency  to  stenosis.  The  intuba- 
tion tubes  will  be  referred  to  in  a  subsequent  paragraph  on  stenosis. 
Later,  for  the  treatment  of  sequential  stenosis,  laryngostomy  is  cura- 
tive in  almost  every  case.  Laryngeal  cartilages  rarely,  if  ever,  unite 
with  cartilaginous  or  bony  tissue.  The  union  is 
always  fibrous  and  is  seldom  rigid. 

INJURIES  OF  THE  TRACHEA 

Injuries  of  the  trachea  may  result  from  any 
form  of  external  violence.  They  are  relatively 
rare  because  of  the  extreme  resiliency  and 
mobility  of  the  trachea.  Penetration  by  cut- 
ting edges  and  splinters  in  wrecks,  or  by  missiles 
and  weapons  in  homicidal  and  suicidal  efforts 
are  not  uncommon.  Healing  cartilage  is  prone 
to  be  associated  with  exuberant  granulations,  re- 
tarded healing,  and  consequent  inflammatory 
infiltration  with  sequential  stenosis  from  cica- 
tricial  contraction  and  cartilaginous  deformity  l^^tLTclLuT^iofTr^. 
and  deficiency 

Treatment- 


Chevalier 


pression  and  other  stenoses 
^,  .  .     ,.        .  .  11    in      the     lower      trachea. 

-The  prmiary    mdication    m   all  They  reach  to  the  bifurca- 

iniuries  to  the  trachea  is  to  insert  a  tracheotomic  tio"-    J]^^^^  ^""^  six  sizes, 

,  .  each  with  its  own  pilot, 

cannula  and    this  should   be  m  all   cases  long 

enough  to  reach  far  below  the  injury.     The  author's  cannulae  (Fig. 

215)  are  long  enough  to  reach  to  the  bifurcation  of  the  trachea.     They 

may  be  shortened  as  needed  for  the  particular  case  though  there  is  no 

harm  in  using  the  full-length  tube,  which  should  in  all  cases  be  worn  until 

complete  heaUng  and  cicatricial  contraction  has  taken  place.     P'or  the 

insertion  of  a  tracheotomic  cannula  it  is  usually  necessary  to  make  an 

incision  rather  than  to  utilize  any  of  the  accidental  wounds  that  may 

be  present.     In  making  the  incision  it  is  necessary  to  avoid  leaving  an 

island  of  cartilage  that  will  die.     The  lumen  of  the  trachea  should 

be  inspected  frequently  with  the  bronchoscope,  both  above  and  below 


420  REGIONAL   SURGERY 

as  well  as  at  the  site  of  injury,  in  order  to  make  sure  that  healing  is 
progressing  properly. 

Mediastinal  Emphysema. — The  most  frequent  complication  is 
mediastinal  emphysema.  If  the  mediastinum  be  not  infected,  the  long 
tracheal  cannula  to  the  bifurcation  will  prevent  asphyxia  until  the 
leaks  are  obliterated  by  inflammatory  processes  and  until  the  air  has 
been  absorbed.  These  long  tracheal  cannulas  have  enabled  the  author 
to  save  a  number  of  cases  of  mediastinal  emphysema  which  would 
otherwise  have  resulted  fatally. 

INFECTIVE   DISEASES   OF   THE  LARYNX  AND   TRACHEA 

The  infections  having  surgical  significance  are  "influenza,"  diph- 
theria, tuberculosis  and  syphilis.  In  most  instances  the  damage  to 
the  larynx  which  requires  the  surgeon's  attention  is  due  to  the  mixed 
pyogenic  infections  complicating  these  specific  infections.  Inflam- 
mation from  any  cause  may  set  up  an  oedema  resulting  in  an  acute 
stenosis  requiring  tracheotomy.  Later  perichondritis,  from  involve- 
ment either  by  the  specific  or  the  mixed  infections,  produces  condi- 
tions of  chronic  stenosis  due  to  infiltration,  chondrial  necrosis,  or 
cicatricial  contraction.  (Edema  may  also  result  from  the  administra- 
tion of  potassium  iodide  and  where  this  is  given  for  a  luetic  lesion  of 
the  larynx  special  watchfulness  is  obHgatory. 

CEdema  of  the  larynx  may  occur  from  the  acute  laryngitis  due  to  the 
so-called  "cold,"  influenza,  measles,  scarlatina,  typhoid  fever,  and  in 


Fig.  2 1 6. — Knife  for  use  through  the  direct  laryngoscope.     {Jackson.) 

acute  and  chronic  nephritis.  Multiple  puncture  by  means  of  the  direct 
laryngoscope  (Fig.  198)  and  the  long  laryngeal  knife  (Fig.  216),  is 
valuable  in  treatment  but  as  a  rule  it  is  much  safer  to  do  a  tracheotomy 
at  once  as  the  onset  of  fatal  dyspnoea  is  apt  to  be  sudden  and  trache-r 
otomy  is  curative  anyway.  Intubation  is  not  to  be  relied  upon  for 
any  cases  except  those  associated  with  diphtheria.^ 

Diphtheria. — The  larynx  may  be  occluded  by  oedema,  the  swelling 
of  perichondritis,  or  accumulated  exudates.  If  an  expert  intubator 
is  at  hand  constantly  for  replacement  in  the  event  of  the  tube  being 
coughed  out,  O'Dwyer's  intubation  is  ideal  for  the  acute  laryngeal 
stenosis  of  diphtheria;  otherwise  tracheotomy  will  be  the  safer  pro- 


LARYNX,  TRACHEA  AND  BRONCHI  42 1 

cedure.  The  tracheal  incision  should  be  as  far  below  the  larynx  as 
possible.  Post-diphtheritic  laryngeal  stenosis  may  be  hyperplastic, 
ankylotic,  paralytic  or  cicatricial.  The  treatment  of  these  is  given  in 
connection  with  stenosis  of  the  larynx. 

Tuberculosis  of  the  larynx  unless  reHeved,  usually  hastens  the  fatal 
termination  of  phthisis,  because  it  diminishes  the  patient's  respiratory 
air-supply  and  because  the  associated  odynphagia  interferes  with  proper 
nutrition.  Relief,  therefore,  is  imperative.  If  the  pulmonary  con- 
dition is  not  too  far  advanced,  the  larynx  will  be  benefited  by  trache- 
otomy, provided  the  patient  will  live  outdoors,  to  which  the  tracheotomy 
is  no  contraindication.  Infiltration  of  the  larynx  is  very  rapidly  re- 
duced by  multiple  galvanopuncture  through  the  direct  laryngoscope 
(Fig.  198),  by  means  of  which  it  can  be  done  with  extreme  accuracy  and 
perpendicularly  to  the  involved  surface.  Should  the  patient  recover 
from  the  pulmonary  condition,  stenosis  of  the  larynx  can  be  relieved 
by  methods  hereafter  mentioned. 

Syphilis  of  the  larynx,  owing  to  the  ravages  of  the  mixed  pyogenic 
infections,  may  require  tracheotomy  for  acute  or  chronic  stenosis. 
No  local  treatment  beyond  tracheotomy  should  be  undertaken  until  a 
long  course  of  treatment  has  completely  mastered  the  basic  disease. 
The  relief  of  stenosis  should  be  undertaken  provided  there  is  not  too 
great  loss  of  the  cartilages  upon  which  patency  of  any  lumen  must 
depend. 

Syphilis  of  the  Trachea. — Any  of  the  tracheal  cartilages  may  be 
involved  in  a  luetic  lesion.  Usually  it  is  an  extension  of  a  similar 
lesion  in  the  larynx.  Prompt  and  energetic  systemic  therapeusis  is 
necessary  to  check  the  ravages  before  the  cartilages  have  been  ex- 
tensively destroyed  by  the  mixed  infections  which  complicate  syphilitic 
processes.  Locally  the  indications  are  for  early  tracheotomy  with  the 
use  of  the  long  tracheal  cannulas  (Fig.  215)  to  maintain  an  ample  lumen, 
temporarily,  to  prevent  asphyxia  and,  for  a  long  time,  to  prevent 
ultimate  stenosis. 

Tuberculosis  of  the  Trachea. — Tuberculosis  of  the  trachea  as  a 
primary  condition  is  very  rare.  It  is  also  rare  as  a  complication  of 
pulmonary  trouble.  Nearly  all  cases  are  associated  with  tuberculous 
lesions  in  the  larynx  of  which  the  tracheal  lesions  are  an  extension. 
Whether  independent  of  laryngeal  disease  or  not,  the  treatment  is  the 
same.  The  regular  antituberculous  regime,  consisting  of  rest  in  bed 
out  of  doors,  23  hours  out  of  24,  sunshine,  milk  and  eggs,  is  curative. 
Locally  it  is  necessary   to   guard   against   asphyxia  by  early  trache- 


42  2  REGIONAL    SURGERY 

otomy  and  the  use  of  the  long  tracheal  cannula  (Fig.  215).  These 
cannulas  can  also  be  used  to  prevent  stenosis  after  the  tuberculous 
process  has  healed.  If  stenosis  results  from  cicatricial  contraction 
and  extensive  chondrial  necrosis,  the  operation  of  laryngotracheostomy 
will  cure.  (See  "Laryngostomy.")  In  the  event  of  the  bursting 
through  of  a  tuberculous  gland  into  the  mediastinal  trachea  or  into 
one  of  the  bronchi,  the  bronchoscope  should  be  used  for  the  scooping 
out  of  the  cheesy  material.  In  the  bronchi,  stenosis  does  not  ordinarily 
follow  such  a  tuberculous  process.  If  there  should  be  any  tendency 
to  stenosis,  bronchial  intubation  can  be  carried  out  through  the  bron- 
choscope. In  case  of  a  mass  of  tuberculous  glands  producing  a  com- 
pression stenosis  of  the  trachea,  the  long  tracheal  cannula  (Fig.  215) 
will  render  good  service. 

Leprosy  of  the  Larynx. — ^Leprous  involvement  of  the  larynx  does 
not  occur  independently  but  is  not  infrequently  associated  with  the 
general  manifestations.  While  the  cause  of  leprosy  is  generally  at- 
tributed to  the  constantly  present  acid-fast  bacilli  that  closely  resemble 
the  bacillus  tuberculosis,  yet  no  therapeutic  results  have  been  obtained 
from  any  method  of  treatment  based  thereon.  Tracheotomy  may 
be  needed  for  stenosis. 

Scleroma  of  the  larynx  and  trachea  may  cause  stenosis.  Trache- 
otomy is  the  best  treatment.  The  Rontgen  ray  and  radium  have 
yielded  good  results  (Emil  Mayer)  applied  through  the  direct 
laryngoscope  or  the  tracheotomic  wound. 

Typhoid  Fever.— CEdema,  ulceration  and  perichondritis,  either 
separately  or  combined,  may  occur  during  the  defervescence  or  con- 
valescence of  typhoid  fever.  The  primary  lesion  may  be  a  thrombosis 
or  an  infection  by  the  typhoid  fever  bacilli  or  it  may  be  a  mixed  pyo- 
genic infection  occurring  at  the  site  of  a  slight  abrasion  in  a  patient 
rendered  vulnerable  by  the  typhoid  toxaemia.  In  any  event,  it  is  the 
pyogenic  mixed  infections  which  do  the  damage.  Oral  antisepsis  with 
25  per  cent,  alcohol  and  frequent  brushing  of  the  teeth  are  the  best 
prophylactic  measures.  Tracheotomy  should  always  be  done  early 
without  waiting  for  dyspnoea.  A  patient  may  die  from  laryngeal  steno- 
sis without  a  fight  for  air.^ 

Pus  collections  should  be  drained  early.  The  vapor  of  compound 
tincture  of  benzoin  evaporated  from  boiling  water  in  the  room  is  bene- 
ficial.    The  laryngeal  lesion  is  almost  never  fatal  of  itself  if  a  trache- 

'^  Chevalier  Jackson.     The  Larynx  in  Typhoid  Fever.     American  Journal  of  the  Medi- 
cal Sciences,  November,  1905. 


LARYNX,  TRACHEA  AND  BRONCHI 


423 


otomy  be  done.  A  greater  or  less  degree  of  stenosis  is  apt  to  follow  owing 
to  loss  of  cartilage.  This  stenosis  should  be  treated  by  prolonged  in- 
tubation or  laryngostomy  as  elsewhere  described. 

BENIGN  TUMORS  OF  THE  LARYNX 

Infective  granulomata  associated  with  lues  and  tuberculosis  are 
dealt  with  under  these  subjects.     Inflammatory  infiltrations  at  times 


Fig.  217.  Fig.  2ii 

Fig.  217. — Schema  illustrating  the  author's  lateral  method  of  exposing  a  growth  in 
the  ventriculus  laryngis,  by  bending  the  patient's  head  to  the  opposite  side  while  the 
second  assistant  fixes  the  larynx  with  his  lingers.  M,  patient's  mouth.  T,  thyroid  car- 
tilage. R,  right  side,  L,  left.  The  tube,  E,  should  be  brought  down  into  the  corner  (B), 
of  the  mouth.     (Jackson.) 

Fig.  218. — Schema  illustrating  removal  of  a  tumor  from  the  upper  part  of  the  laryn.x 
by  the  author's  "ex-tubal"  method  for  large  tumors.  The  large  alligator  basket  punch 
forceps,  F,  is  inserted  from  the  right  corner  of  the  mouth,  and  the  jaws  are  placed  over 
the  tumor,  T,  under  guidance  of  the  eye  looking  through  the  laryngoscope,  L.  This 
method  is  not  used  for  small  tumors.  For  still  larger  tumors  the  heavy  snare  may  be  used 
instead  of  forceps  especially  in  tumors  so  large  that  the  base  cannot  be  seen.     (Jackson.) 


assume  tumor-like  forms.  In  addition  to  these  we  have  pachydermia, 
oedematous  polypi,  singer's  nodules,  and  cysts,  all  of  which  may  be  con- 
sidered benign  tumors  though  really  of  inflammatory  origin.  Pachy- 
dermia and  singer's  nodules  are  usually  amenable  to  hygiene,  careful 
voice  use,  especially  vocal  rest,  pure  air  and  abstinence  from  tobacco. 
Severe  cases,  however,  will  require  touching  with  the  galvano-cautery 


424  REGIONAL   SURGERY 

point  used  bj'  the  direct  laryngoscopic  method.  (Edematous  polypi 
and  cysts  are  to  be  treated  as  given  below  for  true  neoplasms.  Papil- 
loma, fibroma,  myxoma,  fibromyxoma,  and  lipoma  are  of  not  infrequent 
occurrence  in  the  larynx  and  all  require  surgical  removal.  A  few  of  the 
older  generation  of  laryngologists,  such  as  Delavan,  developed  wonder- 
ful skill  in  the  indirect  laryngoscopic  or  mirror  method  of  removal  of 
tumors,  using  the  mirror  with  its  reversed  image,  and  a  bent  forceps. 
It  requires  rare  skill  in  the  case  of  adults  and  cannot  be  used  at  all  in 
the  case  of  children.  Thyrotomy  or  laryngofissure  is  no  longer  justi- 
fiable for  the  removal  of  benign  growths  in  the  larynx.  It  has  been 
abandoned  in  favor  of  the  direct  laryngoscopic  method  (Fig.  202). 
With  practice,  the  greatest  precision  and  accuracy  are  possible.  It 
becomes  necessary  to  decide  whether  the  growth  shall  be  sliced  off  even 
with  the  surface  or  whether  a  certain  amount  of  normal  base  shall  be 
removed.  As  a  rule  it  may  be  stated  that  it  is  preferable  to  remove 
a  small  amount  of  normal  base  with  all  benign  growths  as  this  will  pre- 
vent recurrence,  except  possibly  in  certain  cases  of  papillomata  which 
are  considered  below.  The  application  of  the  galvano-cautery  to  the 
base  is  usually  unnecessary.  Tumors  of  the  ventricle  can  be  removed 
by  the  author's  lateral  method  (Fig.  217).  No  matter  how  large  the 
tumor  it  can  be  removed  through  the  mouth  by  the  author's  extubal 
method  (Fig.  218)  thus  rendering  obsolete  the  operation  of  subhyoid 
pharyngotomy  by  substituting  for  this  relatively  serious  operation  the 
relatively  minor  one  of  direct  laryngoscopy. 

Papillomata  require  special  consideration  because  of  their  great 
tendency  to  recurrence,  especially  in  children.  They  are  in  a  sense 
locally  maUgnant  though  they  do  not  infiltrate,  simply  repuUulating 
on  the  surface.  They  spring  up  at  new  locations,  seldom  at  the  site  of 
previous  removal  if  the  latter  has  been  sufficiently  deep  to  include 
about  half  the  thickness  of  the  mucosa.  In  time  the  surface  of  the 
mucosa  becomes  very  superficially  cicatricial,  which  makes  a  bad  soil 
for  the  development  of  papillomata,  and  they  cease  to  recur.  By  this 
method  the  author  has  been  able  to  cure  every  case  that  has  persisted 
in  the  treatment.  Quite  a  number  of  cases  get  entirely  and  completely 
well  without  any  sign  of  recurrence  after  a  single  operation.  Many 
other  cases,  however,  recur  with  great  persistence  after  repeated  re- 
movals. Thus  it  is  clear  that  there  are  two  classes  of  papillomata. 
Whatever  method  happens  to  be  used  in  the  type  that  is  not  followed  by 
recurrence,  is  apt  to  be  considered  a  superior  form  of  treatment.  Un- 
fortunately the  literature  is  filled  with  reports  of  cases  shortly  after 


*■  LARYNX,  TRACHEA  AND  BRONCHI  425 

operation.  No  case  can  be  pronounced  well  until  a  period  of  at  least 
six  months  has  elapsed  without  any  sign  of  recurrence.  Tracheotomy 
should  be  done  for  all  cases  that  manifest  the  shghtest  dyspnoea  during 
sleep  at  night.  Tracheotomized  cases  will  require  careful  watch  lest 
a  fragment  of  the  papillomata,  which  have  extended  downward  into 
the  trachea,  become  detached  and  occlude  the  tube.  A  large  number 
of  cases  have  occurred  where  the  child  was  found  dead  in  bed  in  the 
morning  from  asphyxia  following  upon  obstruction  of  the  cannula, 
especially  in  small  children  who  of  necessity  wear  a  very  small  cannula. 
Good  results  in  preventing  recurrences  of  papillomata  have  followed 
fulguration  as  advocated  by  Smith  and  also  from  the  use  of  radium  as 
advocated  by  Harris. 

All  forms  of  benign  tumors  of  the  larynx  other  than  papillomata 
rarely  recur,  provided  a  shallow  depth  of  basic  normal  is  included  in 
the  removal.     Cauterization  is  not  necessary, 

BENIGN  TUMORS  OF  THE  TRACHEA  AND  BRONCHI 

The  most  common  form  of  benign  growth  in  this  region  is  multiple 
papilloma  extending  from  the  larynx  into  the  cervical  trachea.  Papil- 
lomata do  occur  also  primarily  in  the  trachea  and  bronchi  but  they  are 
exceedingly  rare.^  Fibromata  come  next  in  frequency.  Aberrant 
thyroid,  lipomata,  enchondromata,  chondrosteomata,  adenomata  and 
lipomata  occur  in  the  trachea,  though  rarely,  and  still  more  rarely  in 
the  bronchi.  Inflammatory  tumors,  especially  oedematous  polypi,  are 
often  associated  with  various  morbid  processes,  and  granulomata  are 
not  uncommon  in  connection  with  foreign  bodies  of  prolonged  sojourn. 

The  endoscopic  removal  of  benign  tumors  of  the  tracheobronchial 
tree  is  a  simple  and  easy  procedure  for  anyone  skilled  in  bronchoscopy. 
The  growths  are  seized  with  tissue  forceps  {E,  Fig.  198)  and  removed. 
The  hemorrhage  is  of  no  consequence  arid  only  local  anaesthesia  is  re- 
quired for  adults.  For  children  no  anaesthesia  whatever,  either  local 
or  general,  is  used.  In  either  instance  any  oozing  that  may  occur  is 
readily  coughed  up  and  does  no  harm.  General  anaesthesia  might  per- 
mit the  accumulation  of  blood  in  some  of  the  smaller  bronchi  which, 
on  breaking  down,  might  produce  complications.  For  similar  reasons 
morphine  or  any  other  antibechic  should  not  be  given  after  operation. 
No  anodyne  is  needed  for  there  is  no  pain,  either  during  or  after  the 
operation. 

^  Chevalier  Jackson.     Peroral  Endoscopj'  and  Laryngeal  Surgery. 


426  REGIONAL   SURGERY 

M.ALIGNANT  TUMORS  OF  THE  LARYNX 

Malignant  disease  of  the  larynx  occurs  most  frequently  as  a  squa- 
mous-celled  epithelioma.  Sarcoma  is  relatively  rare.  One  case  of  endo- 
thelioma has  been  reported.^ 

Diagnosis. — The  differential  diagnosis  between  the  various  forms 
of  malignant  tumors,  and  between  tuberculoma,  luetoma,  and  the 
chronic  granuloma  associated  with  necrosis  of  cartilage,  usually  follow- 
ing trauma,  on  the  one  hand,  and  the  various  forms  of  malignancy  on 
the  other,  can  very  rarely  be  made  on  clinical  appearances.  Reliance 
must  be  placed  upon  biopsy,  the  Wassermann,  luetin  and  tuberculin 
tests  and  the  therapeutic  test  with  mercury  and  potassium  iodide. 
For  the  bioptic  report  to  be  reHable  the  specimen  must  be  large  and 
must  include  an  area  of  basic  normal.  Where  the  tumor  is  small  it 
is  better  to  remove  it  entirely,  including  a  portion  of  the  apparently 
normal  base.  For  this  purpose  direct  laryngoscopy  (Fig.  202)  is  the 
only  reHable  method  because  of  the  great  precision  with  which  the  work 
can  be  done.  The  technique  of  removal  of  a  specimen  will  be  understood 
from  the  description  in  previous  chapters  relating  to  direct  laryngoscopy 
and  to  benign  tumors.  Should  the  bioptic  report  indicate  malignancy, 
in  a  case  where  direct  laryngoscopic  removal  has  entirely  removed  a 
small  growth,  further  and  more  radical  procedure  will  depend  on  the 
histologist's  opinion  as  to  the  completeness  of  removal,  with  a  sufficient 
base  of  normal. 

Prophylactic  Treatment. — The  consensus  of  opinion  among  surgeons 
is  in  favor  of  a  certain  precancerous  condition  at  the  site  of  cancer. 
The  author's  case  records  afford  abundant  evidence  that  it  is  exceedingly 
rare  for  cancer  to  develop  in  a  previously  normal  larynx.  The  history 
of  almost  every  case  of  laryngeal  malignancy  indicates  more  or  less 
annoyance  referable  to  the  larynx  for  so  long  a  period  of  time  that  we 
cannot  ignore  the  influence  of  chronic  laryngitis  as  at  least  a  predis- 
posing cause  of  cancer  of  the  larynx.  In  the  author's  opinion,  specific 
ulcerations  and  benign  growths,  also,  can  prepare  a  soil  more  favorable 
than  normal  tissues  for  the  invasion  of  cancer,  and  a  rapid  cure  of  any 
form  of  a  curable  laryngeal  disease  is  a  prophylactic  measure. 

Palliative  Treatment. — The  odor,  which  is  largely  due  to  the  sapro- 
phytes, can  be  held  in  check  by  the  local  use  of  antiseptics  and  removal 
of  secretions  before  there  is  time  for  decomposition.     Hydrogen  perox- 

^  Endothelioma  of  the  Larynx,  Chevalier  Jackson,  Pennsylvania  Medical  Journal, 
June,  1907. 


LARYNX,  TRACHEA  AND  BRONCHI  427 

ide  in  dilute  solution  as  a  gargle  will  help  remove  secretions  and  dilute 
alcohol  (20  per  cent.)  is  the  most  efficient  non-toxic  antiseptic.  The 
peroxide  solution  should  be  used  first,  the  alcoholic  solution  afterward. 
For  pain,  the  insufflation  of  orthoform  and  menthol  will  postpone  the 
resort  to  narcotics  until  the  last  stages.  In  dysphagia,  seen  especially 
in  epiglottic  and  party-wall  cases,  intubation  of  the  oesophagus  will 
postpone  gastrostomy  until  near  the  end.  For  odynphagia,  due  to 
malignant  ulcer  of  the  epiglottis,  amputation  of  this  structure  by  direct 
laryngoscopy  has  yielded  excellent  palliative  results  in  the  hands  of 
Sir  St.  Clair  Thomson  and  of  the  author.  Dyspnceic  cases  should  be 
tracheotomized  early  and  as  low  in  the  neck  as  possible. 

Curative  Treatment. — Some  day,  doubtless,  a  therapeutic  cure  for 
malignancy  will  be  discovered,  but  up  to  the  present  time  nothing 
absolutely  curative  is  known  except  early  operation.  In  cases,  however, 
that  were  inoperable,  excellent  results  have  been  obtained  by  diathermy.^ 
Excellent  results  from  radium  have  been  obtained  by  Ellen  J.  Patter- 
son and  others.  In  a  case  reported  by  Chevalier  Jackson-  a  sarcoma 
disappeared  under  radium  therapy  and  was  followed  by  a  squamous- 
celled  epithelioma  at  the  site  from  which  the  sarcoma  disappeared. 
The  Rontgen  ray  has  also  been  used.  Though  with  none  of  these 
procedures  have  the  results  been  such  as  to  warrant  their  use  in  any  case 
deemed  operable,  yet  the  results  in  some  instances  have  been  so  remark- 
able that  they  (especially  radium)  should  be  used  in  every  inoperable 
case.     As  urged  by  Semon  operability  depends  on  early  diagnosis. 

No  attempt  at  cure  should  be  made  in  cases  showing  metastatic 
foci,  organic  disease,  feebleness,  alcoholism,  pyorrhea  alveolaris,  or 
extensive  suppurative  disease  of  the  accessory  sinuses.  Nor  should 
any  attempt  be  made  in  a  case  which,  by  its  rapid  progress  or  by  the 
laboratory  findings,  has  shown  a  very  high  grade  of  malignancy.  Im- 
possibility of  entire  removal  by  operation  is,  here  as  elsewhere,  an  ab- 
solute contraindication.  If  the  lymph  nodes  cannot  be  removed,  opera- 
tion is  out  of  the  question,  and  even  if  the  nodes  can  be  removed  opera- 
tion is  contraindicated  unless  the  infected  lymph  channels  by  which  the 
cancerous  process  has  reached  the  nodes  can  also  be  extirpated. 

Choice  of  Operation. — In  early  intrinsic  malignancy  of  very  Hmited 
extent,  not  involving  the  posterior  portion  of  the  larynx,  the  results  of 
thyrotomy  have  been  positively  brilliant.     Nowhere  else  in  the  whole 

^Mr.  W.  Douglass  Harmer.     Diathermy  in  the  Treatment  of  Inoperable  Growths  of 
the  Nose  and  Throat.     Journal  of  Laryngology,  Oct.,  1914. 

^Chevalier  Jackson.     Peroral  Endoscopy  and  Lar\Tigeal  Surgery.     Textbook,  1914. 


428 


REGIONAL   SURGERY 


realm  of  the  surgery  of  malignant  disease  have  such  results  been  ob- 
tained as  from  thjTOtomy  in  such  cases.  This  has  been  abundantly 
proven  by  the  statistics  of  Sir  Felix  Semon,  who  first  demonstrated  the 
efficiency  of  the  operation,  and  his  results  have  been  corroborated  by 
those  of  Sir  St.  Clair  Thomson,  Mr.  Tilley,  Dundas  Grant,  ChevaUer 
Jackson  and  others.  Unfortunately  the  general  statistics  of  thyrotomy 
are  valueless  because  thyrotomy  has  been  done  in  cases  absolutely  un- 
suited  for  the  operation.  The  larynx  is  abundantly  supplied  with  lym- 
phatics which  freely  anastomose  with  each  other,  but,  instead  of  leading 
out  of  the  larynx  by  many  channels,  they  empty  into  two  small  nodes 
on  each  side  without  any  anastomosis  with  the  neighboring  lymphatic 
system.  To  this  peculiar  lymphatic  arrangement  is  due  the  success  of 
thyrotomy  in  the  hands  of  the  few  operators  who  have  Hmited  the  opera- 


FiG.  219.  Fig.  220. 

Fig.  219. — Indirect  (mirror)  view  of  larynx  after  thyrotomy  for  cancer  of  the  right  cord 
in  a  man  of  50  years.  The  left-hand  illustration  shows  condition  eight  weeks  after 
thyrotomy.  The  right-hand  illustration  shows  condition  two  years  later.  An  adventi- 
tious cord  indistinguishable  from  the  original  one  has  replaced  the  lost  cord.     (Jackson.) 

Fig.  220. — The  left-hand  illustration  shows  an  indirect  (mirror)  view  of  the  larynx 
three  years  after  hemilaryngectomy  for  epithelioma  in  a  man  51  years  of  age.  There  is  no 
attempt  to  form  a  new  band  because  the  arytenoid  was  (of  necessity)  removed.  The 
right-hand  illustration  shows  the  lower  pharynx  and  oesophageal  mouth  one  year  after 
laryngectomy  for  endothelioma  in  a  man  aged  68  years.     {Jackson.) 

tion  of  thyrotomy  to  properly  selected  cases.  Sir  Felix  Semon  had  76 
per  cent,  of  lasting  cures,  out  of  22  cases.  Sixteen  of  these  cases  were 
known  to  be  well  after  periods  varying  from  3  to  16  years.  Of 
Chevalier  Jackson's  25  cases  of  thyrotomy  for  malignancy  22  patients 
were  free  from  recurrence  at  the  end  of  one  year.  Seventeen  out  of 
the  25  cases  were  well  and  free  from  recurrence  after  periods  varying 
from  3  to  13  years.  There  was  no  operative  mortality  in  27  opera- 
tions on  the  25  patients.  To  offer  hope  of  success  from  thyrotomy  the 
growth  must  be  of  very  small  extent,  the  party-wall  must  be  free  from  in- 
volvement and  the  growth  must  be  intrinsic;  that  is,  located  below  the 
upper  edge  of  the  ventricular  band,  or,  more  specifically,  upon  the  vocal 
cords,  the  ventricles,  ventricular  bands,  the  interarytenoid  region  or  the 
subglottic  area.     In  cases  in  which  the  involvement  is  extrinsic  (located 


LARYNX,  TRACHEA  AND  BRONCHI  429 

above  the  upper  border  of  the  ventricular  band)  or  has  extended  beyond 
the  Hmits  of  the  larynx,  either  into  the  neck  or  backward  into  the  party- 
wall,  laryngectomy  is  indicated  provided  the  deep  lymphatics  along 
the  oesophagus  are  not  involved  down  into  the  mediastinum.  This 
can  usually  be  determined  by  oesophagoscopy.  The  operation  of 
laryngectomy  has  been  freed  from  a  large  part  of  the  operative  mortality 
which  attached  to  it  in  the  preaseptic  days.  Of  14  laryngectomies 
done  by  Chevalier  Jackson,  two  died  within  30  days,  giving  an  operative 
mortality  of  14  per  cent.;  four  died  within  a  year  of  local  recurrence; 
three  lived  one  year  and  were  thereafter  lost  to  observation;  two  lived 
two  years,  dying  of  recurrence;  one  two  and  one-half  years,  dying  of 
recurrence;  one  three  years,  dying  of  cerebral  hemorrhage;  one  seven 
years,  dying  of  cancer  of  the  stomach.  Recapitulating  this,  of  15  com- 
plete laryngectomies,  eight  of  the  patients  were  free  from  recurrence 
at  the  end  of  one  year,  yet  all  are  since  dead  and  the  average  duration 
of  life  was  but  little  over  one  year.  The  occurrence  of  cancer  in  the 
stomach  seven  years  after  laryngectomy  must  be  looked  upon  as  a 
re-infection,  rather  than  a  re-pullulation  of  the  primary  process.  As 
stated  by  Delavan,  it  is  questionable  if  the  operation  of  total  laryn- 
gectomy has  added  anything  to  the  sum  total  of  human  life. 

The  relatively  normal  larynx  after  thyrotomy  is  shown  in  Fig.  219. 
This  should  be  compared  to  the  mutilated  condition  after  laryngectomy 
as  shown  in  Fig.  220. 

Vocal  Results  after  Operations  on  the  Larynx  for  Malignant  Dis- 
ease.— After  thyrotomy  the  patient  can  be  assured  of  a  loud  and  useful 
voice.  In  cases  where  the  motility  of  the  arytenoid  has  not  been  inter- 
fered with  by  the  operation,  as  shown  by  the  author,  an  adventitious 
band  will  be  formed  out  of  the  cicatricial  tissue,  by  the  traction  of  the 
arytenoid,  and  the  patient's  voice  will  ultimately  become  as  good  as  it 
was  before  the  operation,  having  flexibility,  modulation  and  even  sing- 
ing power.  After  the  modern  operation  of  laryngectomy,  in  which  the 
trachea  is  stitched  to  the  skin  of  the  neck,  the  patient  has  a  choice  be- 
tween a  prothetic  apparatus,  called  an  artificial  larynx,  and  the  develop- 
ment of  a  buccal  voice,  which  depends  upon  swallowed  air.  This  buccal 
voice  has  been  developed  in  some  instances  to  a  remarkable  extent  but 
at  best  the  patient's  condition  after  laryngectomy  is  pitiable  compared 
to  the  condition  after  thyrotomy.  It  is  to  be  hoped  that  the  early 
discovery  of  malignancy  of  the  larynx  w'ill,  in  the  future,  enable  all 
patients  with  intrinsic  laryngeal  cancer  to  have  the  advantage  of  an 
early  thyrotomy. 


43° 


REGIONAL   SURGERY 


Preparation  of  the  Patient  for  Laryngeal  Operation. — Carious  teeth 
should  be  filled  or  removed  and  the  mouth  should  be  put  in  as  healthy 
a  condition  as  possible  by  the  dentist.  Frequent  brushings  of  the  teeth 
with  a  good  paste  and  frequent  rinsings  of  the  mouth  with  25  per  cent, 
alcohol  will  place  the  patient  in  the  best  condition  to  avoid  the  dangers 
of  oral  sepsis.  The  beard  and  moustache  should  be  removed,  if  the 
patient  have  these,  and  the  face  should  be  freshly  shaven  on  the  morning 


Fig.  221. — Illustration  of  thyrotomy  or  laryngofissure.  A,  shows  the  line  of  incision 
through  the  thyroid  cartilage.  The  turbinotome  is  inserted  at  the  cricothyroid  membrane, 
the  points  passing  upward.  (Fig.  222.)  B,  shows  retractors  placed  inside  the  larynx  to 
hold  back  the  wings  of  the  divided  thyroid  cartilage.  In  the  median  line  is  seen  the 
insufflation  anaesthesia  catheter.  The  growth  is  on  the  left  vocal  cord.  Perichondria! 
dissection  begins  at  the  divided  edge  of  the  thyroid  cartilage,  the  retractor  being  shifted 
to  the  bared  cartilage  as  soon  as  sufficient  perichondrium  has  been  separated.     (Jackson.) 


of  operation.     The  general  preparation  should  be  as  for  any  other 
surgical  procedure. 

Anaesthesia  for  External  Laryngeal  Operations. — ^Local  infiltration 
anaesthesia  may  be  used  if  desired  but  the  intratracheal  insufflation  of 
ether,  originated  by  Meltzer  and  Auer,  and  developed  by  Elsberg, 
Janeway  and  others,  affords  so  many  advantages  that  it  has  superseded 
all  other  methods.  As  shown  in  Fig.  221,  the  catheter  is  not  in  the  way 
in  thyrotomy,  and  if  it  is  desired  to  do  laryngectomy,  a  fresh  catheter 
is  inserted  below  as  soon  as  the  larynx  is  drawn  forward,  or  the  trachea 


LARYNX,  TRACHEA  AND  BRONCHI 


431 


is  amputated,  as  the  case  may  be.     The  return  blast  of  air  prevents  all 
trickling  of  blood  or  secretions  into  the  lungs. 

Technique  of  Thyrotomy. — The  patient  should  be  placed  on  an  in- 
clined table  with  the  head  at  the  lower  end,  and  a  sand  bag  should  be 
under  the  neck  to  render  the  larynx  prominent.  As  shown  in  Fig.  221, 
the  skin  is  incised  from  the  level  of  the  hyoid  bone  to  about  the  level  of 
the  second  ring  of  the  trachea.  An  incision  is  then  made  in  the  cricothy- 
roid membrane.  It  is  usually  better  not  to  incise  the  cricoid  cartilage. 
The  turbinotome,  as  shown  in  Fig.  222,  is  inserted  through  the  incision, 
the  blades  being  guided  upward  until  the  outer  blade  is  shghtly  above 
the  thyroid  notch.     The  thyroid  cartilage  is  then  divided  at  one  clip. 


Fig.  222. — Turbinotome  (see  Fig.  221)  in  position  to  make  the  thyrotomic  clip.  The 
table  is  not  shown  steeply  inclined  toward  the  head  as  it  should  be  before  the  turbinotome 
is  inserted.     (Jackson.) 

The  wings  of  the  cartilage  are  spread  with  retractors.  Upon  exposure 
of  the  interior  of  the  larynx,  the  growth  is  usually  found  to  be  more 
extensive  than  was  anticipated,  and  the  surgeon  also  notes  that  the 
vocal  cords  are  not  visible  as  white  ribbon-like  bands,  as  seen  from  above 
in  the  laryngeal  mirror.  The  ventricle  of  the  larynx,  however,  is  always 
conspicuous  as  a  depression,  and  it  is  only  necessary  to  remember  that 
the  cord  is  the  lower  ridge  of  the  depression.  Excision  of  the  growth 
is  now  commenced  by  starting  at  the  anterior  edge  of  the  divided  carti- 
lage and  dissecting  to  the  inner  perichondrium.  The  dissection  is  car- 
ried all  the  way  around  posteriorly  sufficiently  far  so  that  the  excised 
mass  will  be  of  normal  tissue  having  in  its  center  the  growth  as  a  small 
island.  The  external  perichondrium  must  be  kept  intact  or  chondrial 
necrosis  may  result.  Hemorrhage  is  usually  shght  but  occasionally  a 
vessel  will  require  torsion,  rarely  ligation.  The  wound  may  be  short- 
ened vertically  by  a  stitch  or  two  at  top  and  bottom,  but  the  portion 


432  REGIONAL   SURGERY 

corresponding  to  the  incision  of  the  thyroid  cartilage  should  be  left 
open.  Under  no  circumstances  should  the  cartilages  be  stitched,  be- 
cause the  stitches  are  almost  certain  to  tear  out  and  more  or  less  chon- 
drial  necrosis  will  follow.  The  wound  must  be  kept  packed  open  until 
good  fibrous  union  of  the  wings  of  the  thyroid  cartilage  takes  place.  It 
never  becomes  cartilaginous.  In  packing  the  wound  it  is  necessary  to 
use  a  large  piece  of  gauze  all  over  the  front  of  the  neck;  and  into  this, 
at  the  site  of  the  wound,  a  roll  of  gauze  is  forced,  in  order  to  keep  the 
lips  of  the  wound  in  the  soft  tissues  separated.  Under  no  circumstances  . 
should  strings  of  packing  Be  used  lest  they  get  into  the  trachea.  All 
dressings  should  be  wrung  out  of  mercuric  bichloride  solution  i  :  10,000. 

AUer-care. — As  there  is  more  or  less  air  leakage  through  the  wound 
and  dressings,  the  secretions  quickly  become  infected  but  the  wound 
can  be  kept  clean  and  free  from  pus  by  the  use  of  moist  bichloride 
dressings,  i  :  10,000,  replaced  not  less  often  than  every  third  hour 
night  and  day.  No  tracheal  cannula  is  inserted,  but  a  nurse  competent 
to  insert  it  in  case  it  is  necessary  should  be  at  the  patient's  bedside 
constantly  and  she  should  be  competent  to  change  the  dressings.  For 
the  first  48  hours  after  operation  the  patient's  head  should  be 
prevented  from  rotating  by  supporting  it  on  each  side  with  sand  bags. 

Complications. — Secondary  hemorrhage  is  very  rare  but  if  it  occur, 
the  wound  must  be  opened;  and  if  the  bleeding  is  found  to  be  within 
the  larynx,  the  wings  of  the  thyroid  cartilage  must  be  separated  with 
retractors  and  the  bleeding  points  searched  for  and  the  vessel  twisted. 
If  no  vessel  can  be  located  and  the  oozing  continue,  it  may  be  necessary 
to  insert  a  tracheal  cannula  below  for  breathing  and  then  pack  the 
larynx  tightly  full  of  gauze  to  arrest  the  oozing  by  pressure.  In  such 
a  case  the  cannula  should  be  abandoned  as  soon  as  possible,  usually 
at  the  end  of  a  few  hours.  Necrosis  of  cartilage  with  subsequent  steno- 
sis may  result  from  denuding  the  cartilage  of  both  inner  and  outer 
perichondria,  or  from  the  insertion  of  stitches,  both  of  which  are  avoid- 
able. In  case  of  re-operation  an  island  of  cartilage  may  die  if  the  line 
of  fibrous  union  of  the  previous  incision  be  not  followed.  Pulmonary 
compHcations  are  exceedingly  rare  when  the  technique  herein  given 
is  followed. 

Technique  of  Laryngectomy. — The  preparation  and  position  of  the 
patient  are  all  as  given  above  for  thyrotomy;  and  as  there  mentioned, 
intratracheal  ether  insufilation  is  the  preferable  method  of  anaesthesia. 

Two  classes  of  procedure  have  been  followed  for  the  removal  of  the 
larynx.     In  one  (Keen) ,  the  extirpation  begins  above  at  the  thyrohyoid 


LARYNX,  TRACHEA  AND  BRONCHI  433 

membrane,  the  larynx  being  drawn  forward  as  it  is  separated  from  the 
party-wall;  the  amputation  of  the  trachea  is  done  when  sufl&cient  of  the 
larynx  and  the  trachea  have  been  thus  dissected  loose  and  drawn  out. 
The  anaesthesia,  which  has  been  started  by  the  open  method,  is  now  con- 
tinued with  an  insufflation  catheter  inserted  into  the  outdrawn  larynx. 
The  other  method  is  used  after  preliminary  tracheotomy.  The  trachea 
is  divided  below  the  cricoid,  and  the  larynx  is  dissected  away  from 
the  party- wall  by  working  upward  from  below.  Brewer,  Crile  and 
most  American  operators,  prefer  to  do  a  prehminary  tracheotomy 
about  a  week  beforehand  so  as  to  permit  firm  adhesion  between 
the  trachea  and  the  soft  tissues  of  the  neck  to  anchor  the  trachea 
firmly,  thus  avoiding  the  tendency  to  retraction  within  the  thorax, 
when  the  trachea  is  afterward  cut  off  and  stitched  to  the  skin.  The 
inflammatory  adhesions  in  the  neighborhood  of  the  trachea  close  various 
avenues  by  which  infection  could  find  its  way  into  the  mediastinum 
and  this  barrier  can  be  increased  as  desired  by  blunt  dissection  around 
the  sides  of  the  trachea.  A  week  or  lo  days  later  the  patient  is  pre- 
liminarily etherized  with  gauze  over  the  tracheal  cannula.  Then  the 
insufflation  catheter  is  introduced  through  the  cannula,  in  which  it 
must  not  fit  tightly.  The  trachea  is  amputated  (as  low  as  previous 
bronchoscopy  has  indicated)  through  a  T-shaped  incision  of  which  the 
vertical  portion  extends  from  the  neighborhood  of  the  hyoid  bone  down 
as  far  as  needed  though  preferably  not  extending  into  the  preliminary 
tracheotomy  wound.  A  transverse  incision  extending  from  one  sterno- 
cleidomastoid ridge  to  the  other  is  made  at  the  upper  extremity  of  the 
vertical  incision.  Two  anchor  sutures  are  placed  as  shown  at  A,  B, 
Fig.  223.  The  lower  end  of  the  larynx  which  is  then  amputated  from 
the  trachea  and  raised  as  shown  at  2,  in  Fig.  223,  and  very  carefully 
dissected  free  from  the  oesophagus  without  undue  traction.  The  vagi 
and  parathyroids  should  be  carefully  avoided.  One  vagus  and  one 
parathyroid  may  be  removed  if  involved  but  if  both  are  found  invaded 
it  is  better  to  abandon  hope  of  cure.  If  much  dissection  of  the  larynx 
has  taken  place  it  may  be  necessary  to  amputate  a  portion,  but  in 
most  instances  it  will  be  found  better  to  replace  the  tissues  as  nearly 
as  possible  to  their  normal  situation  and  close  the  wound,  inserting  a 
little  drainage.  If,  however,  the  case  has  been  well  selected  for  laryn- 
gectomy there  will  not  be  involvement  of  the  vagi  or  parathyroids,  and 
the  dissection  may  proceed  rapidly  without  approaching  the  neighbor- 
hood of  either  the  vagi  or  the  parathyroids.  Small  snips  with  the  scis- 
sors are  used  to  separate  the  larynx  from  the  oesophageal  and  pharyn- 


434 


REGIONAL   SURGERY 


_^,  .,,\,\\\>^^> 


Fig.  223. — Schematic  illustration  of  laryngectomy  with  the  aid  of  intratracheal 
insufflation  anaesthesia.  At  i  is  shown  the  trachea  and  larynx  exposed  during  anaesthesia 
administered  with  the  Elsberg  apparatus  through  the  silk-woven  catheter,  C,  held  in 
place  with  the  Janeway  bite  block,  D.  The  incision  has  been  made  of  T-shape  as  will 
be  understood  by  the  sutured  wound  in  4.  The  trachea  is  elevated  forward  by  means 
of  the  grooved  director  inserted  carefully  between  the  trachea  and  the  oesophagus.  Two 
anchor  sutures  are  inserted  around  the  first  ring  of  the  trachea  as  shown  a.t  A,  B,  after 
preliminary  incision  of  the  interannular  membrane 

2.  The  trachea  has  been  severed  between  the  cricoid  and  the  first  ring,  drawn  forward, 
and  firmly  fastened  with  the  anchor  sutures  (S).  A  fresh  insufflation  catheter  (C)  has  been 
inserted  for  the  continuation  of  the  anaesthetic.  The  larynx  has  been  dissected  free  from 
the  oesophageal  wall  (£).     The  larynx  is  held  forward  with  the  forceps,  F. 

3.  The  scissors  are  shown  dividing  the  cornu  of  the  thyroid  cartilage.  The  pharyngeal 
wall  has  been  divided  so  as  to  free  the  larynx  posteriorly  and  this  clipping  will  be  continued 
around  over  the  front  so  as  to  free  the  entire  larynx. 

4.  The  wound  is  stitched  together  throughout  its  entire  extent  after  suturing  the 
pharynx,  putting  in  supporting  sutures,  and  securely  anchoring  the  trachea  to  the  skin 
(Modified  from  Molinie). 


LARYNX,  TRACHEA  AND  BRONCHI  435 

geal  wall.  As  much  of  the  latter  must  be  preserved  as  possible.  Usu- 
ally the  tips  of  the  horns  of  the  thyroid  cartilage  are  cut  off  and  left. 
The  thyrohyoid  membrane  is  incised  and  the  aryepiglottic  folds  are 
clipped  free  with  the  scissors.  All  hemorrhage  is  carefully  arrested  at 
each  stage  of  the  procedure;  a  clean  dry  wound  at  each  stage  of  the  opera- 
tion being  essential  to  accurate  work.  The  pharynx  is  sutured  with 
silk,  care  being  taken  not  to  perforate  the  mucosa,  the  edges  of  which  are 
inverted.  Before  the  sutures  arc  placed,  each  layer  of  soft  tissue  is 
carefully  adjusted  so  as  to  afford  the  greatest  possible  support  to  with- 
stand the  strain  of  deglutition.  Before  stitching  the  skin,  the  insuffla- 
tion catheter  and  cannula  are  removed.  The  trachea  is  brought  for- 
ward by  means  of  the  anchor  sutures  and  inserted  in  a  button  hole  in 
the  skin  below  the  laryngectomy  incision;  or,  if  this  incision  has  been 
so  long  as  to  extend  into  the  tracheotomic  wound,  the  cut  end  of  the 
trachea  is  brought  forward  into  the  lower  angle  of  the  wound.  In 
either  case  it  is  securely  stitched  all  around  the  circumference  of  its 
upper  ring.  A  tracheotomic  cannula  is  inserted  and  a  large  dressing 
applied  all  over  the  front  of  the  neck  above  the  cannula.  A  separate 
piece  of  gauze  is  placed  around  the  cannula  as  this  part  of  the  dressing 
requires  very  frequent  removal.  Dressings  should  be  wrung  out  of 
mercuric  bichloride  i  :  10,000.  A  few  strands  of  silkworm-gut  may  be 
used  for  drainage  but  they  should  be  removed  as  early  as  possible. 

The  most  favorable  time  for  the  removal  of  lymph  nodes  in  the  neck 
is  at  the  preliminary  tracheotomy  because  a  rather  extensive  neck  dis- 
section at  that  time  has  the  advantage  of  forming  a  barrier  against  the 
infection  of  the  mediastinum  at  the  laryngectomy  later,  and  if  the  glandu- 
lar involvement  is  such  that  there  is  reason  to  believe  that  the  medias- 
tinal glands  are  also  infected,  it  is  better  to  abandon  all  hope  of  cure  and 
leave  the  tracheotomy  tube  in  place  or  not  according  to  conditions. 
If  there  has  been  the  slightest  dyspnoea  present  at  night,  the  trache- 
otomy will  soon  be  required  for  palliation  and  it  is  better  to  insert  the 
cannula  at  once.  This  exploratory  operation  at  the  time  of  trache- 
otomy will  usually  be  rendered  unnecessary  if  an  oesophagoscopy  has 
previously  been  done,  because  the  lymph  nodes  in  the  mediastinum 
can  be  discovered  by  oesophagoscopy. 

After-care. — Antibechics  and  all  opium  derivatives  must  be  forbid- 
den. Plenty  of  food  must  be  given,  especially  hquids.  The  best 
method  is  by  a  soft  rubber  catheter  or  very  small  stomach  tube  passed 
through  the  mouth.  In  some  instances  it  has  been  passed  through  the 
nose.     The  dressings  over  the  wound  in  the  neck  must  be  changed  every 


436  REGIONAL  SURGERY 

third  hour  while  the  dressing  around  the  tracheotomic  cannula  must  be 
removed  as  often  as  soiled,  in  some  instances  as  often  as  every  few  min- 
utes. If  the  pharyngeal  stitches  give  way  and  serious  leakage  into  the 
neck  wound  occurs,  it  will  be  necessary  to  cut  a  number  of  the  super- 
ficial stitches  to  permit  free  drainage  of  pharyngeal  secretions,  changing 
the  dressings  every  hour  or  oftener  if  necessary.  In  such  cases  the 
wound  may  be  freely  irrigated  by  having  the  patient  attempt  to 
swallow  sterile  water  which  must  be  caught  in  a  pan  externally  to  pre- 
vent it  overflowing  into  the  trachea,  where  the  latter  is  sutured  to  the 
skin.  Usually  the  feeding  tube  may  be  abandoned  and  the  patient 
permitted  to  swallow  strained  sterile  food  in  small  sips  at  the  end  of  a 
week  or  10  days.  The  patient  should  be  propped  up  in  bed  on  the 
second  day  and  got  out  of  bed  on  the  fourth  or  fifth  day. 

Complications. — Operative  compHcations  are  now  much  rarer  than 
formerly.  Pulmonary  complications  are  avoided  by  the  method  of 
Solis-Cohen  of  stitching  the  trachea  to  the  skin  and  by  the  use  of  the 
inclined  position  and  the  intratracheal  insufflation  ansesthesia.  Slough- 
ing of  the  oesophagus,  vagitis  and  septic  mediastinitis  are  indicated  by 
profound  shock,  weak  and  rapid  pulse,  slight  temperature  elevation, 
and  a  white  or  ashy  gray  complexion  out  of  all  proportion  to  the  usual 
post-operative  reaction.  Beyond  stimulants  and  local  drainage  of 
necrotic  areas,  treatment  is  of  little  avail. 

Gliick's  Method  of  Laryngectomy. — No  preliminary  tracheotomy 
is  done.  Instead  of  the  T-shaped  incision  described  above,  a  rectan- 
gular flap  is  formed  by  two  horizontal  incisions,  one  at  the  level  of  the 
hyoid  bone  and  the  other  at  the  level  of  the  third  tracheal  ring,  the  two 
being  joined  by  a  vertical  incision  at  the  left  side  of  the  neck  (Fig.  226). 
This  flap  is  raised  and  turned  over  to  the  patient's  right,  the  flap  in- 
cluding skin,  subcutaneous  cellular  tissue  and  the  platysma.  This  ex- 
poses the  larynx  and  its  overlying  muscles,  of  which  the  sternohyoid 
and  sternothyroid  are  divided  both  above  and  below,  the  section  be- 
tween being  retracted  laterally  with  its  deeper  attachment.  The  supe- 
rior thyroid  arteries  are  exposed  and  ligated.  Then  the  larynx  is  de- 
nuded of  all  its  attachments  by  blunt  dissection  which  is  carried  around 
posteriorly  so  as  to  liberate  the  larynx  from  the  oesophagus,  but  the 
trachea  is  not  amputated.  The  thyrohyoid  membrane  is  divided  by  a 
transverse  incision  close  below  the  hyoid  bone  as  the  larynx  is  drawn 
forward.  Its  interior  is  painted  with  a  10  per  cent,  solution  of  cocaine 
and  a  cannula  is  introduced  and  attached  by  two  sutures  to  the  anterior 
tissues  of  the  larynx.     The  upper  laryngeal  margin  is  now  separated 


LARYNX,  TRACHEA  AND  BRONCHI  437 

from  the  pharyngeal  wall  with  the  scissors,  being  careful  to  preserve  as 
much  of  the  wall  as  possible.  The  larynx  is  drawn  forward  and  freed 
from  the  oesophagus  (Fig.  224).  An  incision  is  now  made  in  the  median 
line  of  the  neck  over  the  trachea  down  as  far  as  the  suprasternal  notch. 
The  thyroid  isthmus  is  divided  between  ligatures  and  the  larynx  is 
amputated.  The  trachea  is  sutured  to  the  skin  of  the  neck  as  originally 
proposed  by  Solis-Cohcn.  The  pharyngeal  wall  is  then  repaired  (Fig. 
225)  with  a  double  row  of  catgut  sutures  and  reinforced  by  suturing 


Fig.  224. — Giiick's  method  of  laryngectomy,  second  stage.    Larynx  drawn  forward  and 
freed  from  the  oesophagus.     {Keen.) 

the  retracted  sternohyoid  and  sternothyroid  muscles.  The  rectangular 
flap  is  then  sutured  in  place  except  the  vertical  portion  of  the  incision 
at  the  left  side  which  is  used  for  the  insertion  of  a  large  gauze  drain. 
(Fig.  226).  Gliick  has  not  used  the  insufHation  anaesthesia,  as  yet,  pre- 
ferring chloroform.  A  fresh  insufflation  catheter  could  be  inserted  as 
the  larynx  is  brought  forward,  instead  of  inserting  the  tracheal  cannula 
as  mentioned  above.  The  chief  objection  that  has  been  raised  by  Crile 
and  other  American  operators  who  have  tried  the  Gliick  method  is 
that  the  trachea,  not  being  anchored  by  the  inflammatory  adhesions 
of  a  preliminary  tracheotomy,  is  very  prone  to  retract  within  the  thorax, 
with,    in    some    instances,    necrosis    of    the    tracheal    rings.     Septic 


438 


REGIONAL   SURGERY 


Fig.  225. — Gliick's  laryngectomy.     Third  stage.     Wound  in  pharynx  being  closed   by 

suture.     {Keen.) 


Fig.  226.— Gluck's    method    of    laryngectomy.     Wound    closed    and    drainage   inserted. 

{Keen.) 


LARYNX,    TRACHEA   AND  BRONCHI  439 

mediastinitis  is  not  so  well  guarded  against  as  when  a  layer  of  in- 
flammatory tissue  is  set  up  between  the  layers  of  cervical  tissues.^ 

Malignant  Tumors  of  the  Tracheobronchial  Tree. — Malignant 
growths  primary  in  the  tracheobronchial  tree  are  rare.  Usually  malig- 
nancy here  is  seen  as  a  compression  stenosis  or  an  extension  from  the 
neighborhood.  The  diagnosis  is  readily  made  with  the  bronchoscope, 
by  means  of  which  a  specimen  for  biopsy  is  readily  taken.  Treatment 
by  radium  has  caused  amelioration  but  no  cures.  Operative  treatment 
is  elsewhere  herein  considered.^ 

DEFORMITIES  OF  THE  LARYNX,  TRACHEA  AND  BRONCHI 

Congenital  deformities  of  the  trachea  and  bronchi  are  exceedingly 
rare.  The  least  rare  is  the  congenital  tracheooesophageal  fistula  usu- 
ally associated  with  an  impervious  oesophagus.  With  rare  exceptions 
the  discovery  has  been  made  only  after  death. 

Acquired  stenoses  of  the  trachea  and  bronchi  are  of  relatively  com- 
mon occurrence  and  may  be  due  to  tuberculosis,  lues,  or  to  the  second- 
ary processes  set  up  around  a  foreign  body.  The  strictures  may  be 
dilated  with  the  author's  bronchial  dilators.  Fig.  227,  used  through  the 


Fig.  227. — Bronchial  dilators  to  fit  the  handle  of  the  forceps  shown  at  D,  Fig.  ic 
They  are  used  through  the  bronchoscope  under  guidance  of    the  eye.     {Jackson.) 

bronchoscope.  Luetic  stenoses  are  usually  very  persistent  in  recurring 
and  may  require  the  wearing  of  a  bronchial  intubation  tube  which  is 
placed  in  situ  with  the  aid  of  the  bronchoscope.  These  bronchial 
intubation  tubes  may  be  worn  for  months  without  causing  ulceration 
but  they  require  removal  every  few  days  for  cleansing  and  they  must 
not  be  used  of  too  great  size.  When  stenosis  is  of  foreign  body 
origin  the  foreign  body  will  usually  be  found  immediately  below  the 
stenosis  from  which  location  it  can  be  removed  after  not  unduly 
forcible  dilatation.  In  these  cases  of  prolonged  sojourn  of  a  foreign 
body  a  large  quantity  of  pus  and  granulation  tissue  is  first  removed 
through  the  bronchoscope  by  the  use  of  bronchoscopic  sponges.  When 
the  foreign  body  is  brought  into  view  it  is  removed  with  bronchoscopic 
forceps,  as  mentioned  on  a  previous  page.     Dilatation  of  the  stenosis 

1  For  review  of  statistics  of  many  operators,  see  article  by  George  E.  Brewer,  in  Keen's 
Surgery,  vol.  vi,  Chapter  CXV,  p.  364. 

2  For  report  of  cure  of  an  endothelioma  by  bronchoscopic  removal  see  article  on 
Bronchial  Obstruction  in  Musser-Kelley's  Handbook  of  Treatment,  Supplementary  Vol- 
ume, 1917. 


440 


REGIONAL   SURGERY 


afterward  is  undertaken  only  when  there  are  signs  of  lack  of  drainage, 
such  as  cessation  of  discharge,  septic  symptoms  and  radiographic 
shadow  of  pus  accumulation.  Of  the  author's  eight  cases  of  prolonged 
sojourn  of  a  foreign  body,  all  except  one  cleared  up  without  after- 
dilatation. 

Stenoses  of  the  trachea  of  hyperplastic  or  cicatricial  origin  are,  in 
many  instances,  amenable  to  the  use  of  increasing  sizes  of  the  author's 
cane-shaped  tracheal  cannulge,  Fig.  215.  In  other  cases  the  operation 
of  laryngotracheostomy  is  required  as  will  be  described  under  the  head- 
ing of  laryngostomy. 


Fig.  228. — From  a  photograph  of  a  child,  two  years  of  age,  taken  six  months  after 
thymopexy.  Diagnosis  of  thymic  tracheostenosis  made  by  bronchoscopy.  Imminent 
asphyxia  immediately  and  permanently  relieved  by  thymopexy.     (Author's  case.) 

Compression  stenoses  of  the  trachea  may  be  due  to  peritracheal, 
malignant  or  benign  growths.  The  author  has  demonstrated  ^  that  the 
thymus  gland  can  and  does  compress  the  trachea  in  certain  cases  (Fig. 
228).  The  degree  of  compression  increases  with  congestion,  thus  me- 
chanically causing  death  by  thymic  tracheostenosis,  usually  attributed 
to  a  hypothetical  '' hyper thymization  of  the  blood,"  "status  lymphati- 
cus,"  etc.  In  a  number  of  instances  the  stenosis  has  been  congenital. 
The  thyroid  gland  has  in  a  number  of  cases  produced  such  a  severe 

^  Chevalier  Jackson.  Thymic  Tracheostenosis,  Tracheostomy,  Thymectomy,  Cure. 
Journal  of  the  American  Medical  Association,  May  25,  1907 


LARYNX,  TRACHEA  AND  BRONCHI 


441 


Stenosis  that  the  patient  would  have  been  asphyxiated  had  not  the 
cane-shaped  tracheotomic  cannula  (Fig.  215)  been  inserted.  Most  of 
the  author's  cases  of  the  latter  class  were  of  malignant  goiter,  in  one 
case  intrathoracic.  In  another  instance  a  congenital  goiter  caused 
what  would -have  been  a  fatal  case  of  "blue  baby"  had  not  a  timely 
tracheotomy  been  done. 

The  diagnosis  is  quickly  made  with  the  direct  laryngoscope  and 
bronchoscope. 


Fig.  229. — Radiograph  of  a  man,  aged  50  years  wiili  an  inoperable  malignant  sub- 
sternal goitrous  compression  stenosis,  the  dyspnoea  of  which  was  completely  relieved  by 
the  author's  cane-shaped  cannula-shown  in  Fig.  215.     {Jackson.) 


The  treatment  of  thymic  tracheostenosis  is  immediate  tracheotomy 
and  the  insertion  of  the  cane-shaped  cannula  Fig.  215,  which  will  insure 
safe  breathing  during  thymopexy  or  subtotal  thymectomy  which  should 
be  done  at  the  same  time  as  the  tracheotomy.  Operable  goiter  causing 
tracheal  stenosis  should  be  dealt  with  surgically.  In  cases  of  inoperable 
malignant  goiter,  the  patient  can  be  kept  alive  indefinitely  so  far  as 
his  tracheal  stenosis  is  concerned  by  means  of  the  cane-shaped  tracheal 
cannula  (Fig.  215)  shown  in  place  in  the  living  patient  in  the  radio- 
graph (Fig.  229). 

Stenoses  of  the  Lar3aix. — Acute  stenosis  of  the  larynx  has  been  re- 
ferred to  under  Injuries  and  Foreign  Bodies. 


442  REGIONAL   SURGERY 

Congenital  stenosis  of  the  larynx  has  been  noted  in  quite  a  number  of 
cases  of  "blue  baby."^  The  diagnosis  can  be  quickly  made  with  the 
direct  laryngoscope. 

Chronic  stenoses  of  the  larynx  come  to  the  surgeon  for  the  abandon- 
ment of  an  intubation  tube  or  a  tracheotomic  cannula  which  has  been 
inserted  in  the  more  or  less  acute  stage  of  the  disease.  Decannulation  or 
extubation  is  prevented  by  various  conditions  which  may  be  classified 
into  the  following  types:  (i)  panic;  (2)  spasmodic;  (3)  paralytic;  (4) 
ankylotic  (arytenoid);  (5)  neoplastic;  (6)  hyperplastic;  (7)  cicatricial;  (8) 
lost  cartilage.  In  the  panic  type,  which  is  seen  only  in  children,  the 
child  has  become  so  accustomed  to  breathing  through  the  neck,  which 
with  a  properly  placed  tracheotomic  cannula  is  so  much  easier  than 
breathing  through  the  mouth,  that  the  patient  becomes  frightened  and 
feels  that  he  is  about  to  asphyxiate  as  soon  as  air  is  shut  off  from  the 
cannula.  In  these  cases  a  cork  should  be  placed  in  the  cannula  after 
having  a  groove  cut  in  the  side  of  the  cork  which 
will  permit  air  to  pass.  Subsequently  other  corks 
with  a  slit  or  groove  of  less  size  can  be  substituted, 
until  the  patient  is  weaned  away.  The  spas- 
modic cases  are  amenable  to  the  same  method. 
Paralytic  Stenosis. — Bilateral  laryngeal  par- 
T^  ^    ^'^^'^rx  ■       .    alysis   causes    a   very  severe  stenosis.     The  best 

riG.    230.  —  Direct         -^  -^  ^ 

laryngoscopic    eviscera-    method  of  treatment  is  by  complete  evisceration 

tion   of   the  I  larynx   for        c  .-i      •    .      •         r  ^u     1  'i-i.  ^u  i.  r 

stenosis.    All  the  tissues    ^^  ^^^  interior  of  the  larynx  with  the  punch  forceps 
inside  the   dotted   line    ^sed    through     the    direct    laryngoscope.     The 

are  removed  with  punch-  r    1 

forceps  under  endoscopic  author  has  had  a  number  of  very  successful  re- 
(/SS.)''^  '^'  '^'"  suits  by  this  method  (Fig.  230).  After  this 
operation  the  patient  recovers  a  loud  useful 
voice,  though,  of  course,  it  will  not  be  as  good  as  if  he  had 
mobile  arytenoids.  In  paralyses  due  to  a  small  lesion  in  the 
neck,  excision  of  the  lesion  and  suture  of  the  divided  ends  of  the 
recurrent  laryngeal  nerve  offer  some  hope.  It  was  successfully  done 
by  J.  Shelton  Horsley  and  CHfton  M.  Miller.^  Doubtless  the  sooner 
after  the  onset  of  the  paralysis  the  suture  is  done  the  better,  because 
of  the  tendency  to  degeneration  of  nerves  and  muscles  from  disuse. 

Ankylotic  stenoses  of  the  larynx  are  amenable  to  endoscopic  eviscera- 
tion through  the  direct  laryngoscope  (Fig.  230). 

Hyperplastic  stenoses  are  curable  by  the  endoscopic  removal  of  the 

^  Chevalier  Jackson.     Peroral  Endoscopy  and  Laryngeal  Surgery.     Text  Book,  1914. 
^  Suture  of  the  Recurrent  Laryngeal  Nerve.    Trans.  Southern  Surg,  and  Gyn.  Assn., 
Dec,  1909. 


EXPLANATION  TO  PLATE  I 

1.  Indirect  view.  Sitting  position.  Male,  aged  fourteen  years.  Post-diphtheritic 
stenosis  cured  by  endoscopic  evisceration.  (See  Fig.  5.)  Known  to  be  well  two  years 
after  decannulation. 

2.  Indirect  view.  Sitting  position.  Male,  aged  18  years.  Patient  very  cyanotic 
because  cannula  was  removed  for  laryngoscopy  and  bronchoscopy.  Cured  by  laryn- 
gostomy.     (See  Fig.  6.)     Still  well  four  years  after  decannulation  and  plastic  closure. 

3.  Indirect  view.  Sitting  position.  Male,  aged  27  years.  Post-typhoid  infiltrative 
stenosis.  Feft  arytenoid  destroyed  by  necrosis.  Cured  by  laryngostomy.  Failure 
to  form  adventitious  band  (Fig.  7)  because  of  lack  of  arytenoid  activity. 

4.  Indirect  view.  Recumbent  position.  Male,  aged  40  years.  Post-typhoid  cicatri- 
cial stenosis.  Cured  of  stenosis  by  endoscopic  evisceration  with  sliding  punch  forceps. 
Anterior  commissure  twice  afterward  cleared  of  cicatricial  tissue  as  in  other  case  shown 
in  Fig.  15.     Ultimate  result  shown  in  Fig.  8. 

5.  Same  patient  as  Fig.  i.     Sketch  made  two  years  after  decannulation  and  plastic. 

6.  Same  patient  as  Fig.  2.     Sketch  made  four  years  after  decannulation  and  plastic. 

7.  Same  patient  as  Fig.  3.     Sketch  made  three  years  after  decannulation  and  plastic. 

8.  Same  patient  as  Fig.  4.  Sketch  made  one  year  after  decannulation,  14  months  after 
operative  clearing  of  the  anterior  commissure  to  form  adventitious  cords. 

9.  Direct  view.  Recumbent.  Female,  aged  16  years.  Web  post-diphtheritic  (?)  or 
congenital  (?)  Patient  had  a  "rough  voice"  since  birth  but  larynx  never  examined 
until  stenosed  after  diphtheria.  Web  removed  and  larynx  eviscerated  with  punch  forceps. 
Recurrence  of  stenosis  (not  of  web).     Cure  by  laryngostomy. 

10.  Direct  laryngoscopic  view.  Child,  aged  22  months.  Post-diphtheritic  hypertro- 
phic subglottic  stenosis.     Cured  by  galvano-cauterization. 

11.  Direct  laryngoscopic  view.  Child,  aged  3  years.  Post-diphtheritic  hypertrophic 
supraglottic  stenosis.  Forceps  excision.  Extubation  one  month  later.  Still  well  four 
years  later. 

12.  Bronchoscopic  view  of  post-tracheotomic  stenosis  following  a  "plastic  flap"  trache- 
otomy done  for  acute  oedema.  Male  aged  47  years.  (Not  treated  because  of  advanced 
nephritis.) 

13.  Direct  laryngoscopic  view.  Anterolateral  thymic  compression  stenosis  in  a  child 
of  18  months.     Cured  by  thymopexy.     Seen  six  months  later.     Still  well. 

14.  Indirect  (mirror)  view.  Laryngostomy  rubber  tube  in  position  in  treatment  of 
post-typhoid  stenosis.     Woman,  aged  30  years. 

15.  Direct  view.  Post-typhoid  stenosis  after  cure  by  laryngostomy.  Male,  aged 
30  years.  Dotted  line  shows  place  of  excision  for  clearing  out  the  anterior  commissure  to 
restore   the  voice. 

16.  Endoscopic  view  of  post-tracheotomic  tracheal  stenosis  from  badly  placed  incision 
and  chondrial  necrosis,  in  a  child  of  three  years.  Tracheotomy  originally  done  for  in- 
fluenzal   tracheitis.     Curcfl   by  tracheostomy. 


PLATE  I. 


Laryngeal  and  tracheal  stenoses.     {Reproductions  oj  Chevalier  Jackson's  oil  paintings  from  life.) 


LARYNX,  TRACHEA  AND  BRONCHI 


443 


hyperplastic  tissue  if  the  latter  is  located  above  the  glottis.  Below 
the  glottis  the  galvanocautery,  applied  through  the  laryngoscope  (Fig. 
198),  after  the  author's  method,  is  uniformly  successful. 

Acromegaly. — Overgrowth  of  the  laryngeal 
cartilages  and  endolaryngeal  tissues,  asym- 
metrical in  character  has  been  observed  by  the 
author.  ^  Treatment  is  of  no  avail  but 
tracheotomy  is  required  early  not  only  for  the 
stenosis  due  to  overgrowth  but  for  the  added 
element  of  spasm  which  may  be  present. 

Cicatricial  stenoses  may  follow  tubercu- 
losis, lues,  perichondritis,  diphtheria,  typhoid 
fever  or  trauma.  In  many  cases  the  cica- 
trices are  enabled  to  obliterate  the  lumen  of 
the  larynx  entirely  because  of  more  or  less 
loss  of  the  cartilaginous  framework  which 
normally  should  keep  the  laryngeal  lumen 
open.  Plastic  operations  with  transplantation 
of  cartilage  have  not  as  yet  been  successful. 
If  there  is  not  excessive  loss  of  cartilage,  how- 
ever, practically  every  case  of  cicatricial 
stenosis  can  be  cured,  the  tracheal  fistula 
closed  and  normal  breathing  through  the 
mouth  restored.  The  treatment,  however, 
is  long  and  tedious,  requiring  untiring 
patience  and  careful  watching  to  be  successful. 

Three  methods  of  treatment  have  been 
used.  The  first  that  should  be  tried  is  incom- 
plete endoscopic  evisceration  through  the  di- 
rect laryngoscope.  If  there  is  arytenoid 
mobility  great  care  should  be  taken  not  to  in- 
jure the  arytenoids,  nor  to  remove  too  much  of 
the  interior  muscles,  because  the  pull  of  the 
arytenoids  will  afterward  assist  greatly  in 
forming  an  adventitious  cord  from  the  cica- 
tricial tissue,  as  demonstrated  by  the  author.  ^ 
If  endoscopic  evisceration  fails,  prolonged 
tried.     Increasing    sizes    of    intubation    tubes. 


Fig.  231. — The  author's 
self-retaining  intubation 
tube  for  the  treatment  of 
chronic  laryngeal  stenosis. 
The  tube  (.4)  is  intro- 
duced through  the  mouth, 
then  the  post  (B)  is 
screwed  in  through  the 
tracheal  wound.  Then  the 
block  (B)  is  slid  into  the 
wound  the  square  hole  in 
the  block,  guarding  the 
post  against  all  possibility 
of  unscrewing.  If  the 
threads  of  the  post  are 
properly  fitted  and  tightly 
screwed  up  with  a  hemo- 
stat,  however,  there  is  no 
chance  of  unscrewing,  and 
gauze  packing  is  used  in- 
stead of  the  block  to  main- 
tain a  large  fistula.  The 
shape  of  the  intubation 
tube  has  been  arrived  at 
after  long  clinical  study 
and  trials,  and  cannot  be 
altered  without  risk  of  fall- 
ing into  errors  that  have 
been  made  and  eliminated 
in  the  development  of  this 
shape.     iJacksoH.) 


intubation 
modeled  to 


may    be 

suit   the 


'  Chevalier  Jackson. 
^  Chevalier  Jackson. 


Peroral  Endoscopy  and  Laryngeal  Surgery.     Text  Book,  1914. 
Peroral  Endoscopy  and  Laryngeal  Surgery,  1914. 


444  REGIONAL   SURGERY 

case,  are  used.  The  ordinary  intubation  tube  sold  for  use  in  diph- 
theria is  of  no  value  for  this  purpose.  For  adults  increasing  adult  sizes 
must  be  used.  Excellent  results  have  been  obtained  by  the  author 
with  the  tube  shown  in  Fig.  231.  With  this  in  place  the  patient  is 
perfectly  safe,  so  far  as  the  coughing  out  of  the  tube  is  concerned,  be- 
cause of  the  post.  From  three  months  to  a  year  is  required  for  cure. 
Should  this  fail,  laryngostomy  must  be  resorted  to. 

Lar3mgostoiny. — Laryngostomy  is  the  name  given  to  the  operation 
of  spHtting  the  larynx  anteriorly  and  keeping  it  open  for  a  long  period 
of  treatment  during  which  the  interior  of  the  larynx  becomes  epiderma- 
tized  with  epidermal  epithelium.  The  obstructing  cicatrices  are  soft- 
ened and  caused  to  disappear  by  the  elastic  pressure  of  soft  rubber 
tubes  inserted  in  the  laryngeal  lumen.  With  a  sufficient  degree  of 
patience  on  the  part  of  both  patient  and  surgeon,  a  cure  can  be  obtained 


Fig.  232. — Author's  tubinotome,  originally  designed  for  turbinotomy  and  afterward 
found  ideal  for  splitting  the  thyroid  cartilage  in  thyrotomy  (laryngofissure)  and  laryn- 
gostomy.    {Jackson.) 

in  the  most  stubborn  cases,  provided  there  has  not  been  too  great  a  loss 
of  the  laryngeal  cartilaginous  framework.  From  six  months  to  a  year 
or  more  may  be  required. 

The  technique  of  the  operation  is  simple.  The  turbinotome  (Fig.  232) 
is  inserted  through  the  tracheotomic  wound,  as  shown  in  Fig.  222,  the 
point  projecting  upward.  The  anterior  laryngeal  wall  is  thus  divided 
at  one  clip  in  the  median  line  which  has  been  locally  infiltrated  with  a 
solution  of  one-tenth  of  i  per  cent,  of  cocaine,  the  injection  being 
intradermatic,  not  hypodermatic.  The  larynx  is  spread  with  retractors. 
If  there  are  web-like  bands  running  across  the  larynx  they  are  excised. 
Thick  masses  of  infiltration  may  also  be  extirpated.  If  the  posterior 
laryngeal  wall  is  much  infiltrated,  a  vertical  linear  incision  is  then  made 
on  the  anterior  surface  of  the  back  wall  of  the  larynx,  exercising  great 
care  not  to  go  through  to  the  oesophagus.  The  skin  is  stitched  to  the 
deeper  tissues  though  preferably  not  to  either  the  cartilage  or  the  peri- 
chondrium. This  will  cause  a  dipping  down  of  the  skin  surface  so  as  to 
start  the  epithelialization  of  the  interior  of  the  larynx  with  epidermal 


LARYNX,    TRACHEA    AND   BRONCHI 


445 


epithelium.  The  apparatus  (Fig.  233,  using  the  laryngostomy  cannula, 
Fig.  234),  is  then  inserted  and  the  wound  dressed  by  inserting  a  large 
piece  of  gauze  over  the  front  of  the  neck.  At  the  site  of  the  wound  a 
roll  of  gauze  is  forced  down  to  cause  the  wound  to  gape.  Bits  or  strings 
of  gauze  are  not  used  lest  they  get  into  the  trachea. 

After-care. — Success  depends  altogether  on  the  after-care  and  unless 
the  surgeon  is  prepared  to  devote  daily  attention  for  many  months, 


Fig.  233.  Fig.  234. 

Fig.  233.— Schema  showing  the  author's  method  of  laryngostomy.  The  hollow 
upward  metallic  branch  (N)  of  the  cannula  (C)  (see  also  Fig.  234)  holds  the  rubber  tube 
(R)  back  firmly  against  the  spur  (£)  on  the  backwall  of  the  trachea._  Moreover,  the 
air  passing  up  through  the  rubber  tube  (R)  permits  the  patient  to  talk  in  aloud  whisper, 
the  external  orifice  of  the  cannula  being  occluded  most  of  the  time  with  the  cork  {K). 
(Jackson.) 

Fig.  234. — The  author's  laryngostomy  cannula.  A  short  piece  of  rubber  tubing 
in  increasing  sizes,  and  of  proper  length,  is  placed  over  the  upper  branch.  {Jackson.) 

laryngostomy  should  not  be  undertaken.  The  apparatus  is  removed 
'  at  first  every  day  and  afterward  every  alternate  day.  About  once  each 
week  the  size  of  the  rubber  tubing  is  increased  until  it  has  reached  the 
size  of  No.  40  French  for  an  adult.  The  metallic  part  of  the  apparatus 
is  maintained  the  same,  without  increase.  In  children  the  limit  of 
size  of  the  rubber  tubing  will  be  reached  according  to  age.  When  the 
maximum  size  has  been  reached,  it  is  continued  throughout  the  period 
of  treatment.  The  vertical  extent  of  the  external  wound  must  not  be 
allowed  to  diminish  but  must  be  kept  as  an  open  trough.  Applications 
of  scarlet  red  in  10  per  cent,  ointment  will  favor  epithelialization.  When 
a  sufficient  lumen  has  been  reached  and  maintained  for  three  or  four 
months  completely  epithehalized,  the  apparatus  may  be  abandoned, 
and  a  dressing  placed  over  the  wound  lightly  without  pressure.  When 
the  patient  has  been  able  to  sleep  quietly  at  night  for  six  months  with 
the  neck  wound  covered,  the  case  may  be  pronounced  well  and  the  plas- 
tic operation,  Fig.  235,  may  be  done  to  close  the  fistula. 

Closing  of  Tracheal  Fistidoe. — Any  time  within  a  few  weeks  after 
tracheotomy  the  wound  will  close  promptly  when  the  cannula  is  aban- 


446  REGIONAL   SURGERY 

doned;  but  tracheal  fistulse  resulting  from  prolonged  wearing  of  a  can- 
nula become  lined  with  epidermal  epithelium  and  often  refuse  to  heal. 
They  can  be  readily  closed  by  the  plastic  operation  shown  in  the  schema 
(Fig.  235).  This  method  is  applicable  also  to  closure  of  the  laryngo- 
stomic  opening  after  cure  of  laryngeal  stenosis. 


Fig.  235. — Plastic  operation  for  the  closure  of  a  tracheal  fistula.  The  flaps  are  turned 
epidermal  surface  inward.  The  raw  surface  of  the  flaps  is  then  covered  by  drawing  the 
skin  together  thereover  with  a  second  series  of  sutures.  The  turning  in  of  hair-bearing 
epidermis  must  be  avoided.     {Jackson.) 

TRACHEOTOMY 

Indications. — Tracheotomy  is  indicated  as  a  therapeutic  measure 
in  certain  diseases  of  the  larynx  such  as  tuberculosis,  lues,  and  papil- 
lomata.  Perichondritis  and  necrosis  of  the  larynx  and  trachea  are 
much  benefited  by  tracheotomy.  The  chief  indication  for  the  opera- 
tion is,  however,  stenosis  of  the  larynx  from  any  cause  whatever.  In 
the  absence  of  stenosis  it  may  be  indicated  for  respiratory  arrest,  for 
the  insufflation  of  oxygen  or  other  means  of  artificial  respiration. 
Formerly  it  was  used  for  the  removal  of  foreign  bodies  from  the  larynx 
and  trachea,  but  since  the  development  of  direct  laryngoscopy  and 
bronchoscopy  it  is  regarded  as  justifiable  to  do  a  tracheotomy  in  foreign 
body  cases  only  when  needed  for  dyspnoea. 

Mortality. — The  mortality  of  tracheotomy  is  less  than  one-half  of 
I  per  cent,  if  considered  apart  from  the  conditions  calling  for  it. 
Formerly  it  was  blamed  for  many  deaths  which  were  due  to  lack  of 
promptness  in  performing  it.  It  should  always  be  done  early  rather 
than  late.  Of  472  tracheotomies  done  in  their  clinic  and  elsewhere  by 
Dr.  Patterson  and  the  author,  there  was  a  mortality  of  six  (1.27  per 
cent.).  This  includes  all  cases  that  died  from  any  cause  whatever 
within  a  week  of  the  operation. 

Anaesthesia  should  be  local.  General  anaesthesia  not  only  is  un- 
necessary but  introduces  an  enormous  element  of  risk  out  of  all  pro- 
portion to  the  anaesthetic  risk  in  the  general  run  of  surgical  work.  The 
dangers  of  general  anaesthesia  may  be  primary  from  asphyxia  or  second- 
ary from  aspiration  of  infected  blood,  pus  or  secretions  owing  to  the 


LARYNX,  TRACHEA  AND  BRONCHI 


447 


abolition  of  the  cough  reflex.  All  that  is  necessary  is  to  infiltrate  the 
skin  by  the  intradermatic  (not  hypodermatic)  injection  of  salt  solution 
to  which  one-tenth  of  i  per  cent,  of  cocaine  has  been  added. 

Technique. — For  tracheotomy  the  essentials  are  a  knife  and  a  pair  of 
hands.  Even  eyesight  is  not  absolutely  essential,  and  the  author  twice 
has  been  quite  successful  in  a  dark  room  with  nothing  but  a  knife. 
Such  performances,  while  life-saving  and  justifiable  in  emergencies, 
are  to  be  avoided  by  early  operation  with  proper  preparation.  Besides 
general  operating  instruments  a  tracheal 
cannula  should  be  provided  and  a  good 
headlight  is  of  great  service.  The  tracheo- 
tomic  cannulas  of  the  shops  are  all  defective 
because  they  are  too  short.  When  the 
reactionary  swelling  has  set  in,  the  cannula 
is  withdrawn  from  the  interior  of  the 
trachea  though,  unfortunately,  a  thin 
stream  of  air  still  passes  and  the  fact  that 
the  inner  end  of  the  cannula  is  not  in  the 
trachea  is  overlooked.  The  author  has 
devised  a  proper  set  of  cannulae  each  one 
with  its  own  pilot  (Fig.  236). 

The  classical  description  of  the  division 
of  tissues  after  identification  layer  by  layer 
on  a  grooved  director  is  a  needless,  time- 
wasting  encumbrance.  The  skin  and  sub- 
cutaneous cellular  tissues  should  be  cut  at 

the  first  stroke  of  the  knife.  This  incision  should  be  exactly  in  the  me- 
dian line  and  should  extend  from  the  thyroid  notch  to  the  suprasternal 
notch.  The  subcutaneous  tissues  are  then  divided  by  shallow  incisions 
the  vessels  being  drawn  aside  with  retractors  held  by  an  assistant,  or 
seized  before  division,  as  may  seem  best.  The  back  of  the  point  of  the 
knife  may  be  used  as  a  blunt  dissector  if  desired.  The  trachea  should  be 
laid  bare  at  the  cricoid  first  and  then  followed  downward.  When  the 
entire  trachea  from  the  cricoid  to  about  the  fifth  ring  has  been  bared, 
the  thyroid  isthmus  being  retracted  either  upward  or  downward  as 
seems  easiest,  and  all  bleeding  having  been  arrested,  the  trachea  may 
be  incised  at  the  desired  location,  including  at  least  three  tracheal  rings 
in  the  incision  and  taking  care  not  to  incise  the  posterior  tracheal  wall. 
It  has  been  customary  to  describe  two  operations,  the  high  and  the  low 
tracheotomy.     This  is  a  great  misfortune.     The  trachea  should  be  laid 


Fig.  236.  —  Authors' 
tracheotomic  cannula  and 
pilot,  for  ordinary  cases. 
The  defects  of  the  cannulae 
of  the  shops  are  eliminated. 
For  deep  tracheal  stenoses 
the  cane-shaped  cannula  Fig. 
215  is  used.  Both  forms  are 
made  in  six  sizes. 


448  REGIONAL   SURGERY 

bare  first  and  then  the  site  of  incision  determined  upon;  and,  unless 
for  some  very  special  reason,  the  incision  should  never  be  higher  than 
the  second  ring  of  the  trachea.  High  tracheotomies  have  caused  many 
cases  of  laryngeal  stenosis  by  approaching  too  closely  to  the  subglottic 
tissue  which  is  very  prone  to  chronic  hyperplasia. 

The  wound  in  the  trachea  is  spread  with  a  Trousseau  dilator  or  with 


5\,CY  no  Y*^  -  \S\tvuo 

Fig.  237. — Schema  showing  the  author's  method  of  rapid,  emergency  tracheotomy. 
First  stage.  The  hands  are  drawn  ungloved  for  the  sake  of  clearness.  The  upper  hand 
is  the  left,  of  which  the  index-finger  and  the  thumb  are  used  to  repress  the  sternocleidomas- 
toid muscles,  the  finger  and  thumb  being  close  to  the  trachea  in  order  to  press  backward 
out  of  the  way  the  carotid  arteries  and  the  jugular  veins.  This  throws  the  trachea  forward 
into  prominence  and  one  deep  slashing  cut  will  incise  all  of  the  soft  tissues  down  to  the 
trachea.     {Jackson.) 

a  hemostat,  and  the  tracheotomic  cannula  is  inserted.  A  stitch  or  two 
may  be  placed  at  the  upper  and  lower  angles  of  the  skin  wound  but 
under  no  circumstances  should  the  whole  wound  be  stitched  up  tightly 
close  to  the  tracheotomic  cannula.  The  wound  around  the  cannula 
should  be  packed  with  gauze,  using  the  center  of  a  large  piece  for  the 
purpose  so  that  no  end  can  get  down  into  the  trachea.  A  filter  piece 
of  gauze  is  then  placed  over  the  tracheal  cannula,  both  pieces  of  gauze 
being  attached  to  the  tape  with  a  safety  pin. 

It  must  always  be  remembered  that  if  the  dyspnoea  is  not  com- 
pletely reheved  upon  the  insertion  6i  the  cannula,  that  something  is 


LARYKX,  TRACHEA  AND  BROXCHI 


449 


wrong.  It  may  be  occlusion  of  the  cannula  with  exudates  or  secretions; 
but  usually  it  is  because  the  stenosis  is  in  the  lower  trachea.  It  is  aston- 
ishing how  many  cases  have  died  unreHeved  by  tracheotomy  simply 
because  a  cane-shaped  cannula,  such  as  that  shown  in  Fig.  215,  was  not 
used,  the  stenosis  being  beyond  the  reach  of  the  ordinary  cannula. 

Emergency  Technique. — The  stabbing  of  the  cricothyroid  mem- 
brane or  the  attempt  at  stabbing  of  the  trachea  so  long  advocated  as  an 


Fig.  238. — Illustrating  the  author's  method  of  emergency  tracheotomy.  Second 
stage.  The  fingers  are  drawn  ungloved  for  the  sake  of  clearness.  In  operating  the  whole 
wound  is  full  of  blood  and  the  rings  of  the  trachea  are  felt  with  the  left  index-finger,  which 
is  then  moved  slightly  to  the  operator's  left,  while  the  knife  is  slipped  down  along  the  left 
index  finger  to  exactly  the  middle  line  when  the  trachea  is  incised.     (Jackson.) 

emergency  tracheotomy  has  led  to  many  cases  of  stenosis  and  even  worse 
disasters.  A  better,  more  certain  and  equally  quick  method  is  the  auth- 
or's "two  stage,  finger  guided"  method  as  shown  in  Figs.  237  and  238. 
As  shown  in  Fig.  239,  the  detailed  anatomy  is  ignored,  and  schematic 
gross  anatomy  memorized.  The  first  incision  divides  the  skin,  thyroid 
isthmus  and  all  tissues  down  to  the  trachea,  the  rings  of  which  are 
divided  at  the  second  incision  guided  by  the  sense  of  touch  in  the  tip 
of  the  left  forefinger.  The  trachea  cannot  be  seen  because  of  the  free 
hemorrhage. 


45° 


REGIONAL   SURGERY 


CRICOID. 
AVOID 


Fig.  239. — Schema  of  practical  gross  anatomy  to  be  memorized  for  emergency  trachept- 
omy.  The  middle  line  is  the  safety  line,  the  higher  the  wider.  Below,  the  safety  line 
narrows  to  the  vanishing  point  VP.  The  upper  limit  of  the  safety  line  is  the  thyroid  notch 
until  the  trachea  is  bared,  when  the  limit  falls  below  the  first  tracheal  ring.  In  practice  the 
two  dark  danger  lines  are  pushed  back  with  the  left  thumb  and  middle  finger  as  shown  in 
Fig.  237,  thus  throwing  the  safety  line  into  prominence.  The  tracheal  incision  should  be 
vertical  and  exactly  in  the  middle  line  of  the  trachea.     (Jackson.) 


Fig.  240.— Schematic  illustration  of  Dr.  Ellen  J.  Patterson's  method  of  attaching 
the  tapes  to  tracheotomic  cannulse.  Near  the  end,  A,  a  slit  is  cut  in  the  tape  with 
scissors.  The  end,  A,  is  then  passed  through  the  slot  in  the  tape  plate  from  the  under  side 
as  shown  at  D.  The  end,  B,  is  then  pulled  through  the  slit  in  the  tape  and  drawn  taut  as 
shown  at  C.  The  tape  must  be  not  less  than  16  mm.  (^  in.)  wide  and,be  good,  strong 
linen.     (Jackson.) 


LARYNX,  TRACHEA  AND  BRONCHI  45 1 

After-care  of  Tracheotomized  Patients. — Dressings  should  be  wrung 
out  of  mercuric  bichloride  solution  i :  10,000,  and  should  be  changed 
every  third  hour  with  the  exception  of  the  filter  piece  which  should  be 
changed  as  often  as  it  is  soiled,  probably  every  few  minutes,  at  times. 
A  nurse  trained  in  tracheal  work  should  be  on  hand  to  sponge  away 
secretions  when  they  are  coughed  up.  This  must  be  done  quickly  be- 
fore the  secretions  are  aspirated  back  into  the  tube.  Under  no  circum- 
stances should  any  antibechic,  such  as  the  opium  derivatives,  be  given 
because  the  cough  reflex  is  the  watchdog  of  the  lungs,  and  if  uninter- 
fered  with  there  will  be  no  danger  of  aspiration  pneumonia.  Routine 
hospital  post-operative  care  has  resulted  in  an  enormous  post-operative 
mortahty  from  accidents  to  the  tube,  with  no  help  present  other  than 
nurses  and  internes  inexperienced  in  tracheotomic  work. 

(ESOPHAGOSCOPY  AND  GASTROSCOPY 

(Esophagoscopy  and  gastroscopy  are  procedures  using  tubes  which 
serve  as  specula  for  the  examination  of  the  interior  of  the  oesophagus 
and  the  stomach. 

Instruments. — All  practical  cesophagoscopes  and  gastroscopes  are 
straight  and  rigid  tubes.  Some  effort  has  been  made  from  time  to 
time  to  develop  angular  cesophagoscopes  (the  best  one  is  that  of  Lewi- 
sohn),  but  their  necessity  is  not  apparent  because  a  straight  and  rigid 
tube,  introduced  by  sight,  can  be  passed  in  less  than  one  minute  of 
time  through  the  oesophagus  into  the  stomach  of  any  human  being 
whose  mouth  can  be  opened.  To  do  this  safely  and  quickly,  however, 
requires  practice.  The  tubes  most  used  at  present  are  Briinings, 
(Fig.  197),  Kahler's  (Fig.  196)  and  Chevalier  Jackson's  (Fig.  198). 
Good  results  have  been  obtained  with  all  of  these  instruments  for  work 
in  the  oesophagus,  but  only  the  last  is  available  for  use  in  the  stomach 
because  the  hght  from  the  two  first-mentioned  is  inadequate  to  reach 
through  a  sufficiently  long  tube.  An  cesophagoscope  with  ballooning 
attachment  has  been  devised  by  Mosher.^  Various  accessory  instru- 
ments needed  are  shown  in  Fig.  198  and  are  hereinafter  mentioned. 

Indications. — Any  symptom  of  discomfort  or  difficulty  in  swallow- 
ing calls  for  an  immediate  oesophagoscopy.  Any  case  of  suspected 
foreign  body  in  the  oesophagus  is  an  urgent  indication  for  oesophagos- 
copy, and  no  external  operation  on  the  oesophagus  is  ever  justifiable, 
for  foreign  body  or  disease,  without  a  previous  oesophagoscopy.  While 
radiography  has  taught  us  much  about  the  oesophagus,  oesophagoscopy 

^Loeb's  Operative  Surgery  of  the  Nose,  Throat  anH  Ear. 


452  REGIONAL   SURGERY 

is  indicated  in  every  case  of  oesophageal  disease  before  operation. 
OEsophagoscopy  and  radiography  together  have  led  to  an  accuracy  of 
diagnosis  which  has  put  the  surgery  of  the  oesophagus  on  an  entirely 
new  basis. 

Contraindications. — The  only  contraindications  to  oesophagoscopy 
are  aneurism  and  a  serious  state  of  disease  of  the  cerebral  blood-vessels. 
Even  these  are  not  a  contraindication  in  case  of  foreign  body  in  the 
oesophagus.  If  the  patient  is  admitted  in  a  serious  state  of  water 
starvation,  oesophagoscopy  or  any  other  procedure  is  contraindicated 
until  water  has  been  introduced  into  the  system  either  through  the 
bowels  or,  if  necessary,  by  means  of  a  gastrostomic  opening.  Diagnosis 
should  in  all  cases  wait  until  the  very  dangerous  condition  of  water 
starvation  has  been  ameliorated. 

Anaesthesia. — No  anaesthetic,  general  or  local,  is  needed  for  the 
passing  of  an  oesophagoscope  in  either  adults  or  children,  either  for 
diagnosis  or  for  the  removal  of  foreign  bodies.  The  only  exception  to 
this  is  in  case  of  foreign  bodies  of  very  large  size  with  one  or  more  rough 
points  which  might  seriously  injure  the  oesophageal  wall  if  withdrawn 
through  a  tightly  spasmodically  contracted  oesophagus.  If  the  foreign 
body  is  large  in  one  diameter  only,  no  matter  how  sharp  and  pointed, 
the  mechanical  problem  of  its  removal  can  be  solved  without  anaesthesia. 
The  personal  equation  of  the  operator,  however,  must  be  considered, 
and  it  is  perfectly  justifiable  to  use  an  anaesthetic  if  the  operator  feels 
that  he  can  do  better  work.  Unquestionably  the  oesophagoscope  is 
more  easily  introduced  with  an  anaesthetic  than  without;  but  it  is 
equally  true  that  anaesthesia  introduces  a  risk  in  the  oesophagoscopy 
that  is  out  of  all  proportion  to  the  anaesthetic  risk  in  any  other  class  of 
cases,  because  of  the  interference  with  respiration  likely  to  follow  the 
displacement  of  a  foreign  body  overridden  by  the  oesophagoscope,  which 
results  in  a  compression  stenosis  of  the  trachea. 

Preparation  of  the  Patient. — The  teeth  should  be  brushed  and  the 
mouth  cleansed  by  rinsing  with  peroxide  of  hydrogen  followed  by  a 
gargle  of  25  per  cent,  alcohol.  In  all  oesophageal  cases  that  are  stenotic, 
the  oesophagus  should  be  emptied  of  food  and  secretions  by  regurgita- 
tion, which  is  usually  easily  done  voluntarily  by  the  patient  subject 
to  chronic  stenosis. 

Position  of  the  Patient. — The  easiest  method  of  introduction  of  the 
oesophagoscope  is  by  the  author's  "high-low"  method.  For  this  the 
head  of  the  patient  must  be  beyond  the  end  of  the  table  but,  as  shown 
by  Boyce,  it  must  not  hang  in  the  Rose  position.     On  the  contrary, 


LARYNX,  TRACHEA  AND  BRONCHI  453 

it  must  be  elevated  and  moderate  extension  should  be  made  at  the 
occipito-atloid  joint.  The  shoulders  should  be  about  2  in.  beyond  the 
head-end  of  the  table,  the  head  being  out  in  the  air  supported  by  the 
second  assistant  as  shown  in  Fig.  241.  The  second  assistant  makes 
extension  of  the  head  with  his  left  hand,  and  to  prevent  fatigue  the  left 
elbow  is  rested  on  the  left  knee,  the  left  foot  being  elevated  on  a  stool, 
the  top  of  which  is  26  in.  lower  than  the  top  of  the  table.  The  second 
assistant's  left  arm  passes  under  the  patient's  neck  so  that  the  index- 


FiG.  241. — Chevalier  Jackson's  "high-low"  method  for  oesophagoscopy.  First  stage. 
The  patient's  head  is  high,  the  vertex  being  about  15  cm.  above  the  table-top  (adult  patient) 
during  the  introduction  of  the  oesophagoscopic  tube-mouth  into  the  right  pyriform  sinus. 
It  is  but  very  slightly,  if  at  all,  lowered  during  the  passage  through  the  cervical  oesophagus 
(second  stage),  or  through  the  upper  thoracic  oesophagus  (third  stage). 

finger  can  be  used  to  hold  in  place  the  bite-block  (G,  Fig.  198).  Wide 
gagging  must  not  be  used.  The  sitting  position  is  sometimes  used  for 
oesophagoscopy,  but  it  has  the  great  disadvantage  that  secretions 
flow  down  and  obscure  the  field  and  are  much  more  difiicult  to  remove 
against  gravity.  In  case  of  children,  the  patient  is  very  much  more 
easily  controlled  in  the  recumbent  position.  One  nurse  holds  the  two 
wrists  of  the  child  down  on  the  table  while  another  nurse  holds  down 
the  knees.  This,  with  an  experienced  head-holder,  gives  absolute  con- 
trol of  the  patient.     As  shown  by  the  author,  it  is  necessary  to  remember 


454 


REGIONAL   SURGERY 


that  the  upper  third  of  the  oesophagus  goes  backward  as  well  as  down- 
ward. Therefore  if  the  head  be  drawn  backward  as  if  the  neck  were 
to  be  shaved,  an  anteriorly  convex  curve  is  put  in  the  cervical  oesopha- 
gus. These  points  are  the  foundation  of  the  author's  "high-low" 
position  for  cesophagoscopy,  which  has  made  oesophagoscopy  easy  for 
the  operator  and  the  patient. 

Introduction  of  the  (Esophagoscope. — The  oesophagoscope  is  intro- 
duced through  the  right  pyriform  sinus,  the  position  of  which,  in  the 


Fig.  242. — Chevalier  Jackson's  "high-low"  method  of  oesophagoscopy.  Fourth 
stage.  The  patient's  head  is  lowered  until  the  vertex  is  about  5  cm.  (adult  patient)  below 
the  table-top  during  the  passage  of  the  tube-mouth  through  the  hiatus,  the  abdominal 
oesophagus  and  the  cardia. 

recumbent  patient,  is  shown  in  the  schema,  Fig.  243.  To  understand 
the  schema  it  is  necessary  to  remember  that  the  cricoid  cartilage  lies 
tightly  against  the  cervical  spine  and  there  is  no  room  to  pass  a  tube 
between  these  two  structures.  At  the  side,  however,  the  pyriform 
sinuses,  through  which  food  normally  passes,  are  elastic  though  col- 
lapsed channels,  through  which  the  oesophagoscope  is  readily  intro- 
duced until  stopped  by  the  contraction  of  the  cricopharyngeus  which 
obstructs  the  tube-end  like  a  wall.  When  this  obstacle  is  encountered 
it  is  necessary  to  elevate  the  distal  end  of  the  oesophagoscope  in  an 
anterior  direction,  the  lip  of  the  tube-mouth  being  upward.     In  a  few 


LARYNX,  TRACHEA  AND  BRONCHI 


455 


moments  spasm  of  the  cricopharyngeus  will  relax  and  the  tube  will 
enter  readily  into  the  cervical  oesophagus,  which  is  seen  to  open  on 
inspiration  and  to  close  on  expiration.  Passing  downward,  the  whole 
oesophagoscope  pointing  in  a  backward  direction  as  if  aiming  for  the 
lumbar  region,  the  thoracic  oesophagus 
is  seen  not  to  entirely  close  during 
expiration  while  the  negative  pressure 
in  the  thorax  causes  it  to  gape  widely 
on  inspiration.  A  narrowing  is  noticed 
at  the  crossing  of  the  left  bronchus, 
after  which  it  will  be  noticed  that  the 
lumen  of  the  oesophagus  begins  to  turn 
anteriorly.  At  this  point  the  head 
must  be  dropped  and  the  oesophago- 
scope must  be  pointed  anteriorly  (up- 
ward in  the  recumbent  patient)  as  if 
aiming  for  the  anterior  superior  spine 
of  the  ilium  (Fig.  242).  This  direction  of  the  tube  is  necessary  to  pass 
the  hiatus  oesophagus  and  the  abdominal  oesophagus.     The  hiatus  is 


Fig.  243. — Scheme  for  finding  the 
right  pyriform  sinus  in  the  author's 
"high-low"  method  of  oesophagos- 
copy.  The  circle  represents  the 
cricoid  cartilage.  VB,  ventricular 
bands.  A,  right  arytenoid  eminence, 
over  which  the  tube-mouth  must 
not  be  "hooked."  P,  right  pyriform 
sinus  through  which  the  asophago- 
scope  must  be  passed.     (Jackson.) 


Fig.  244. — Schematic  illustration  of  the  author's  "  high-low  "  method  of  oesophagoscopy. 
Fourth  stage.  To  pass  the  hiatus  the  head  is  dropped  from  the  position  CL  (which  it  has 
occupied  during  the  first,  second  and  third  stages)  to  the  position  shown  by  the  dotted  linCj 
T,  the  head  and  shoulders  at  the  same  time  being  moved  (without  rotation)  to  the  patient's 
right.     (Jackson.) 


noted  to  be  tightly  contracted  in  a  puckered  rosette,  sometimes  more 
or  less  slit  like.  Gentle  pressure  and  a  few  moments  waiting,  the  tube 
pnesbodoperly  centered  over  the  hiatus,  will  result  in  relaxation  of  the 
as    primic  contraction  and  the  oesophagoscope  will  slip  readily  through 


456  REGIONAL    SURGERY 

the  hiatus  and  abdominal  oesophagus  into  the  stomach.  This  "high- 
low"  method  of  oesophagoscopy  makes  cesophagoscopy  very  easy,  after 
experience  is  acquired.  The  proper  position  of  instruments  and  patient, 
as  here  given,  easily  brings  the  axis  of  the  ahmentary  canal  straight, 
from  the  right  corner  of  the  mouth  to  the  greater  curvature  of  the 
stomach  (Fig.  244). 

During  introduction  the  aspirating  attachment  to  the  oesophago- 
scope  keeps  the  field  free  from  fluid.  Particles  of  food  and  very  thick 
secretions  may  need  to  be  wiped  away  with  the  sponge  carrier  armed 
with  gauze  sponges. 

(Esophagoscopy  for  Foreign  Bodies. — The  oesophagoscopic  removal 
of  foreign  bodies  has  reached  such  a  high  state  of  perfection  that  it  may 
be  stated  that  with  an  operator  of  experience,  any  foreign  body  that  has 
gone  down  through  the  mouth  may  be  removed  the  same  way,  and  that 
the  bhnd  use  of  probangs,  forceps  and  bougies  and  also  the  operation 
of  external  oesophagotomy  are  all  unjustifiable  for  foreign  bodies,  unless 
an  experienced  oesophagoscopist  is  unavailable.  It  must  be  borne  in 
mind,  however,  as  pointed  out  by  John  C.  DaCosta^  that  the  cesoph- 
agoscope  in  the  hands  of  the  inexperienced  may  be  more  dangerous 
than  external  oesophagotomy. 

Of  206  cases  of  oesophagoscopy  for  foreign  bodies  in  the  author's 
cHnic,^  the  foreign  body  was  removed  in  198  and  escaped  downward 
in  eight.  In  the  206  cases  there  was  one  death,  a  woman  of  56  years 
of  age  with  advanced  nephritis.  Three  other  deaths  occurred  in 
patients  admitted  with  severe  laceration  of  the  oesophagus  from  violent 
attempts  at  removal  by  blind  methods  prior  to  admission. 

Almost  all  foreign  bodies  lodge  in  the  oesophagus  at  the  level  of  the 
upper  thoracic  aperture  (Fig.  245)  because  there  is  a  physiological  nar- 
rowing at  this  point.  In  this  location  the  foreign  body  may  be  removed 
either  by  the  oesophagoscope  with  long  forceps  or  with  the  author's 
oesophageal  speculum  (Fig.  246)  and  the  alligator  forceps  of  Mosher. 

In  the  case  of  smooth,  round  foreign  bodies,  such  as  coins,  the  in- 
truder can  be  seized  as  soon  as  seen  and  removed.  Not  so,  however, 
with  sharp  and  rough  foreign  bodies.  The  mechanical  problem  of  the 
removal  must  be  studied  so  that  the  intruder  can  be  brought  out  with- 
out trauma.  The  oesophagus,  is,  surgically,  one  of  the  most  intolerant 
organs  in  the  body.  It  requires  only  slight  trauma  to  cause  oesopha- 
gitis, sloughing,  septic  mediastinitis  or  mediastinal  emphysema,  all  of 

'  John  C.  DaCosta.     Modern  Surgery.     7th  Edition,  1914. 

2  Chevalier  Jackson.     Peroral  Endoscopy  and  Laryngeal  Surgery,  1914. 


LARYNX,  TRACHEA  AND  BRONCHI 


457 


Fig.  245. — Radiograph  of  cuff-link  in  the  asophagus  of  a  child  17  months  old.  Cuff- 
link removed  by  ccsophagoscopy,  bloodlessly,  through  the  mouth,  without  anaesthesia, 
general  or  local.     {Author's  case.     Radiograph  by  Johnston  and  Grier.) 


c 


"1 


33 


^ 


Fig.  246. — The  author's  asophageal  speculum,  useful  in  the  upper  third  of  the  cesoph- 
agus  for  the  diagnosis  and  treatment  of  disease  and  for  the  removal  of  foreign  bodies. 
Two  sizes  are  needed,  one  for  adults  and  one  for  children. 


458 


REGIONAL   SURGERY 


Fig.  247. — The  problem  of  the  horizontally  transfixed,  sharply  pointed  foreign  body 
in  the  oesophagus.  The  point,  D,  has  caught  as  the  bone,  A,  was  being  swallowed.  The 
end,  E,  was  forced  down  to  C,  by  food  or  by  blind  attempts  at  pushing  the  bone  downward. 
The  wall,  F,  should  be  pushed  laterally  out  to  /,  permitting  the  forceps  to  grasp  the  end, 
M,  of  the  bone,  B.  Traction  in  the  direction  of  the  dart  wUl  disimpact  the  bone  and  permit 
it  to  rotate  so  that  one  point  comes  into  the  tube-mouth,  while  the  other  point  trails  harm- 
lessly behind  during  extraction.  The  author's  rotation  forceps  that  touch  only  at  the 
points  must  be  used  to  permit  rotation  as  shown  at  K.     {Chevalier  Jackson.) 


Mk 


H<^ 


A 


Fig.  248. — Schema  illustrating  the  endoscopic  closure  of  open  safety  pins  lodged  point 
upward.  The  closer  is  passed  down  under  ocular  control  untU  the  ring,  R,  is  below  the 
pin.  The  ring  is  then  erected  to  the  position  shown  dotted  at  M,  by  moving  the  handle, 
H,  downward  to  L  and  locking  it  there  with  the  latch,  Z.  The  fork,  A,  is  then  inserted 
and  engaging  the  pin  at  the  spring  loop,  K,  the  pin  is  pushed  into  the  ring,  thus  closing 
the  pin,  which  is  then  safely  removed  with  forceps.     (Jackson.) 


Fig.  249. — At  E,  F,  is  shown  how  the  oesophageal  wall  would  be  perforated  by  at- 
tempted withdrawal  of  an  open  safety  pin  lodged  point  upward  in  the  oesophagus.  A, 
B,  C,  D,  show  successive  stages  of  a  safe  method  of  removal  by  passing  the  pin  into  the 
stomach,  turning  and  removing  by  special  forceps  which  retain  the  pin  securely,  though 
permitting  it  to  turn.  The  entire  procedure  is  under  cesophagoscopic  guidance  of  the  eye. 
{Jackson^ 


LARYNX,  TRACHEA  AND  BRONCHI  459 

which  are  almost  invariably  fatal.  In  case  of  transfixed  bodies 
they  should  be  seized  by  one  end  as  shown  in  the  schema  (Fig. 
247).  In  the  case  of  foreign  bodies  such  as  safety  pins,  lodged  point 
upward,  violent  removal  would  result  in  fatal  trauma  of  the  oesophagus. 
The  pin  can  be  closed  before  removal  with  the  author's  closer  shown  in 
Fig.  248,  or  it  can  be  passed  into  the  stomach,  there  turned,  and  re- 
moved as  shown  schematically  in  Fig.  249.     In  case  of  round  disc-like 


Pig.  250. — Lateral  radiograph  showing  safety  pin  lodged  point  upward  in  the  cesoph- 
agus  of  an  infant,  11  months  old.  Removed  by  cesophagoscopy,  bloodlessly  through 
the  mouth,  without  anassthesia.  (Author's  case.  Radiographic  plate  made  by  Dr. 
George  Q  Johnston.) 

bodies  having  a  sharp  projection  as  in  a  campaign  button,  it  is  neces- 
sary to  seize  the  pin  by  the  point,  if  the  point  is  upward.  Good  forceps 
will  give  a  sufficiently  tight  hold  for  this  to  be  done.  If  necessary,  the 
disc  can  be  seized  after  the  paint  is  safely  in  the  tube.  If  the  point  be 
out  laterally,  it  is  necessary  to  seize  the  disc  at  a  point  opposite  the  pin 
so  as'to  permit  rotation.  For  this  purpose  the  author's  rotation  forceps 
that  touch  only  at  the  points  (A',  Fig.  247)  are  needed. 


460 


REGIONAL   SURGERY 


The  average  time  required  for  the  oesophagoscopic  removal  of  a 
foreign  body  is  one  or  two  minutes.  Very  complicated  mechanical 
problems,  such  as  in  case  of  open  safety  pins,  double-pointed  tacks, 
and  the  hke,  may  prolong  the  operation  to  10  or  15  minutes.  In 
the  early  days  of  oesophagoscopy  the  procedure  was  prolonged  some- 
times to  an  hour  or  two  without  subsequent  reaction,  if  manipulations 
were  gentle. 


Fig.  251. — Steel  dilator  of  Mosher  in  place  fully  expanded  in  the  hiatal  and  abdominal 
oesophagus  of  a  living  patient,  undergoing  treatment  for  hiatal  oesophagismus  (so-called 
"cardiospasm.")     {Author's  case.) 

The  reader  interested  in  the  many  mechanical  problems  of  oesophago- 
scopic foreign-body  extraction  is  referred  to  a  special  work  on  the 
subject.^ 

Fluoroscopic  Removal  of  Foreign  Bodies. — The  fluoroscopic  guid- 
ance of  forceps  passed  through  the  moiith  for  the  removal  of  foreign 
bodies  has  been  successful  in  a  few  cases,  and  fatal  in  a  number  of  other 

^  Chevalier  Jackson.     Peroral  Endoscopy'  and  Laryngeal  Surgery,  1914. 


LARYNX,  TRACHEA  AND  BRONCHI  46 I 

cases.  It  is  exceedingly  dangerous  as  compared  with  cesophagoscopy 
under  guidance  of  the  eye  looking  through  the  cesophagoscope,  and  it 
is  necessarily  limited  to  those  cases  in  which  the  foreign  body  is  very 
dense  to  the  ray.  It  is  but  little  better  than  the  now  obsolete,  often 
fatal,  bhnd  methods  with  probang,  forceps  and  bougie. 

GASTROSCOPY 

Gastroscopy  has  given  to  the  diagnosis  of  stomach  diseases  all  the 
certainty  of  actual  inspection.  The  interior  of  the  left  two-thirds  of 
the  stomach  is  open  to  gastroscopic  exploration  in  every  case.  In 
some  cases  the  pyloric  end  can  also  be  inspected.  Should  a  mass  exist 
at  the  pylorus,  the  abdominal  palpator  externally  can  move  the  pyloric 
end  over  in  front  of  the  gastroscope,  unless  there  are  extensive  adhesions. 
The  greatest  usefulness  to  the  surge  on  is  in  the  early  diagnosis  of  mahg- 
nancy  (Figs.  17  and  18,  Plate  II).  A  specimen  of  growth  can  be  re- 
moved with  ease  and  precision  by  anyone  who  is  experienced  in  cesopha- 
goscopy. Gastric  ulcer  (Fig.  15,  Plate  II)  has  been  diagnosticated 
and  located  in  many  instances.  The  condition  as  well  as  the  patulency 
of  any  gastroenterostomic  opening  can  be  determined  in  a  few  minutes 
as  was  first  done  by  the  author  in  consultation  with  Dr.  Wm.  L.  Rod- 
man on  one  of  the  latter's  patients.^  The  oesophagogastroscope  shown 
at  H,  in  Fig.  198  can  be  passed  in  one  minute  into  the  stomach  of  any 
patient  with  a  normal  oesophagus  and  whose  mouth  can  be  opened. 
The  procedure  is  without  mortality  in  careful  and  skilful  hands. 
The  only  deaths  occurring  in  1000  cases  by  various  operators  were 
attributable  to  perforation  of  the  oesophagus  by  several  operators  who 
had  never  learned  cesophagoscopy,  and  all  were  in  the  early  days  of 
gastroscopy,  before  the  absolute  safety  of  the  passage  of  the  open  tube 
by  sight  had  been  demonstrated  by  the  author. 

The  instrument  is  passed  into  the  stomach  as  already  described  un- 
der introduction  of  the  cesophagoscope.  Once  the  stomach  is  reached 
the  exploration  proceeds  in  the  collapsed  stomach  by  commencing  at 
the  left  end  of  the  stomach  and  inserting  the  cesophagoscope  until  the 
greater  curvature  is  reached.  Then  the  tube-mouth  is  moved  about 
I  cm.  to  the  right  and  withdrawn  to  the  cardia.  It  is  then  moved  to  the 
right  another  centimeter  and  pushed  gently  downward  again  until  the 
greater  curvature  is  reached.  Thus  the  mucosal  lining  of  the  stomach 
is  examined  just  as  the  field  of  the  microscope  is  searched  with  the 
mechanical  stage.     A  window  may  then  be  inserted  in  the  proximal 

1  American  Journal  Medical  Sciences,  July,  igoS. 


462  REGIONAL    SURGERY 

end  of  the  gastroscope,  and  the  stomach  inflated,  as  suggested  by 
Mosher;  or  the  lens  system  gastroscope  of  Janeway  may  be  inserted 
through  the  safely  passed  open  tube. 

The  open- tube  gastroscope  {H,  Fig.  198)  is  very  useful  for  the  re- 
moval of  dangerous  foreign  bodies,  such  as  open  safety  pins,  glass,  etc., 
from  the  stomach.  In  case  of  very  small  foreign  bodies,  a  fluoroscopist 
with  the  double-plane  fluoroscope,  perfected  for  the  author  by  Dr. 
George  W.  Grier,  will  be  of  great  assistance.  The  gastroscopist  works 
with  all  the  safety  afforded  by  direct  vision,  while  following  with  the 
tube-mouth  the  verbal  guidance  of  the  fluoroscopist. 

The  gastroscope,  H,  Fig.  198,  is  very  useful  in  enabling  the  oesoph- 
agoscopist  working  through  the  mouth  to  give  the  abdominal  surgeon 
whose  hands  are  in  the  abdominal  cavity,  information  as  to  the  condi- 
tion of  the  interior  of  any  suspected  portion  of  the  stomach  which  the 
surgeon  desires  to  place  in  front  of  the  gastroscope.  This  has  been 
used  by  J.  Hartley  Anderson  for  the  identification  of  a  bleeding  point 
in  the  case  of  a  bleeding  gastric  ulcer.  In  working  thus  it  is  necessary 
for  the  oesophagoscopist  to  have  a  separate  sterile  organization  entirely 
apart  from  the  sterile  organization  of  the  abdominal  operator. 

INJURIES  OF  THE  (ESOPHAGUS 

Injuries  of  the  oesophagus  from  within  are  usually  inflicted  by  for- 
eign bodies  or  attempts  at  removal.  The  best  treatment  is  bismuth 
subnitrate  given  dry  on  the  tongue.  Calomel  may  be  added  from  time 
to  time.  Food  should  be  sterile  liquids  for  five  days,  unless  there  is  a 
mediastinal  or  pleural  perforation,  in  which  case  nothing  should  be 
given  by  mouth.  Water  starvation  may  be  prevented  by  enteroclysis, 
but  rectal  ahmentation  is  so  unreliable  that  a  gastrostomy  is  justifiable. 
If  the  foreign  body  has  invaded  the  pleura,  immediate  thoracotomy's 
indicated  for  drainage  as  well  as  extraction.  Corrosive  poisons,  such 
as  lye  or  acids,  require  an  antidote  followed  by  bismuth  subnitrate 
taken  dry.  Burns  and  scalds  should  also  be  treated  by  bismuth.  It 
is  not  usually  advisable  to  pass  an  oesophagoscope  during  the  acute 
stage  of  endooesophageal  injuries.  For  the  subsequent  stenosis  cesoph- 
agoscopic  treatment,  as  elsewhere  herein  given,  is  by  far  the  safest 
and  most  effective  form  of  treatment.  Practically  all  stenotic  cases 
can  be  cured.  The  first  oesophagoscopic  examination  may  be  made 
at  the  end  of  two  or  three  weeks. 

Injuries  of  the  oesophagus  from  without  never  occur  without  ex- 
tensive injury  of  surrounding  structures.     Perforations  by  missiles  and 


LARYNX,  TRACHEA  AND  BRONCHI  463 

projectiles,  stab  wounds,  and  the  like  usually  require  cleansing,  removal 
of  foreign  matter,  and  suture  of  the  external  wound,  or  drainage,  as 
conditions  seem  to  indicate.  If  there  is  a  large  open  laceration  of  the 
neck  involving  the  oesophagus,  the  oesophageal  laceration  should  be 
separately  sutured  first,  invaginating  the  edges.  In  all  such  cases  the 
breathing  should  be  watched.  Dyspnoea,  which  may  be  due  either  to 
laryngeal  oedema  or  bilateral  laryngeal  paralysis,  demands  immediate 
tracheotomy. 

ANOMALIES  AND  DEFORMITIES  OF  THE  (ESOPHAGUS 

Anomalies.- — The  most  common  congenital  anomaly  of  the  oesopha- 
gus is  in  the  form  of  a  tracheooesophageal  fistula.  Such  an  infant  rarely 
lives  because  of  other  coincident  malformation.  If  it  survive  for  a 
time,  food  going  into  the  lungs  soon  gives  rise  to  a  bronchopneumonia. 
A  few  instances  have  been  recorded  where  a  valve-like  fold  of  mucosa 
prevented  the  leakage.  It  is  not  uncommon  for  the  cesophagoscopist 
to  find  unexplained  narrowings  in  the  oesophagus  of  adults  and,  as 
suggested  by  A.  Brown  Kelly,  some  of  these  may  have  been  a  congen- 
ital narrowing  whose  lumen  was  not  sufficiently  small  to  prevent  ade- 
quate swallowing  of  food. 

Congenital  webs  of  the  oesophagus  and  other  narrowings  are  readily 
dilated  with  the  oesophageal  bougie  used  through  the  oesophageal 
speculum.  Fig.  246,  or  the  cesophagoscope,  H,  Fig.  198.  Being  done 
by  sight,  there  is  practically  no  danger  unless  an  undue  degree  of 
force  be  used.  Such  congenital  contractions  rarely  recur  after 
divulsion. 

The  oesophagus  may  be  bifid,  or  may  end  in  a  blind  pouch,  its  con- 
tinuation being  a  cord-like  structure  without  lumen  connecting  the 
pouch  with  the  pervious  oesophagus  below.  Such  a  condition  has  so 
far  not  been  amenable  to  any  form  of  treatment. 

STENOSES  OF  THE  (ESOPHAGUS 

Stenoses  of  the  oesophagus  may  be  due  to  compression  by  any  form 
of  perioesophageal  disease,  or  to  cicatricial,  spasmodic,  or  neoplastic  con- 
strictions of  the  oesophageal  lumen. 

Paralysis  of  the  oesophagus  should  be  mentioned  in  connection  with 
stenotic  diseases,  for,  while  not  strictly  a  stenosis,  it  produces  the  same 
symptoms  inasmuch  as  the  patient  is  unable  to  swallow  even  Hquids, 
in  severe  cases.     Strange  as  it  may  seem,  gravity  plays  no  part  in  swal- 


464  REGIONAL   SURGERY 

lowing.  A  man  can  swallow  "uphill"  with  his  mouth  lower  than  his 
stomach,  with  ease;  but,  erect,  he  cannot  swallow  "downhill"  unless 
the  muscular  apparatus  of  the  oesophagus  is  in  good  working  order. 
This  phenomenon  doubtless  comes  from  the  phylogenetic  recency  of 
the  upright  posture. 

The  most  frequent  causes  of  compression  stenoses  are  aneurism, 
maHgnancy,  auricular  or  aortic  enlargement,  lymphatic  infiltration  or 
calcification  and  lordosis.  Bassler  has  reported  a  case  due  to  hyper- 
trophy of  the  auricle;  Kahler  one  of  compressive  stenosis  from  cancer 
of  the  liver;  and  Gottstein  one  from  pressure  of  a  calcareous  area  in  the 
pleura.  The  diagnosis  is  readily  made  by  oesophagoscopy,  which  shows 
a  normal  mucosa  with  a  lumen  compressed  by  a  mass  external  to  the 
tube  (Fig.  14,  Plate  II).  The  lateral  extent  of  the  mass  will  often  be 
shown  by  radiography.  Fluoroscopy  is  the  best  method  of  diag- 
nosticating aneurism,  the  presence  of  which  is  a  contraindication  to 
oesophagoscopy. 

The  treatment  will  depend  on  the  nature  of  the  compressive  disease 
so  far  as  any  attempt  at  cure  is  concerned.  Palliative  treatment  by 
oesophageal  intubation  has  yielded  excellent  results.  The  method  is 
described  under  Mahgnant  Disease  of  the  (Esophagus. 

Spasmodic  Stenosis. — The  most  frequent  form  of  spasmodic  steno- 
sis is  due  to  contraction  of  the  cricopharyngeus.  It  is  one  of  the  con- 
ditions that  produces  the  symptom  called  "globus  hystericus."  In 
some  instances  the  stenosis  is  so  severe  that  the  patient  suffers  seriously 
from  inanition.  This  form  is  readily  cured  by  a  single  passage  of  the 
oesophagoscope  of  large  size,  in  all  cases  that  are  not  really  hysterical. 
True  hysterical  conditions  are  prone  to  recur,  but  they  are  very  much 
rarer  than  the  true  form  of  spasm,  erroneously,  labeled  "globus  hys- 
tericus," and  which  is  often  unassociated  with  difficulty  in  swallowing. 

Hiatal  CEsophagismus  {so-called  ^'■Cardiospasm^'). — Until  demon- 
strated oesophagoscopically  it  was  common  to  call  these  cases  "cardio- 
spasm," under  the  mistaken  idea  that  the  spasm  existed  at  the  cardia 
where  a  sphincter  was  supposed  to  exist.  As  demonstrated  by  the 
author,^  the  spasm  is  at  the  hiatus  and  not  at  the  cardia. 

The  diagnosis  formerly  was  inferential  and  often  erroneous.  Today 
the  diagnosis  is  very  readily  made  with  absolute  certainty  by  the  passage 
of  the  oesophagoscope  which  reveals  a  large  dilatation  of  the  thoracic 
oesophagus,  the  mucosa  showing  a  whitish,  furred,  macerated  epitheHum 

^  Chevalier  Jackson.  Tracheobronchoscopy,  CEsophagoscopy  and  Gastroscopy,  1Q07. 
Ibid.,  International  Medical  Congress,  1913,  Section  XV. 


EXPLANATION  TO  PLATE  II 

1.  Introitus  oesophageus.  Normal.  Dark  line  must  not  be  understood  as  a  gaping. 
Lumen  collapsed  shut.  Man  of  36  years.  The  fold  of  the  cricopharyngeus  is  ad- 
vanced from  the  posterior  wall. 

2.  Intrathoracic  oesophagus.  Unusual  view,  but  normal.  More  usual  appearance 
is  with  radiating  folds  as  in  Fig.  10. 

3.  (Esophagus  at  hiatus  oesophageus,  normal.  Note  axis  of  lumen.  Man  of  sixty. 
More  usual  appearance  is  a  tightly  puckered  rosette. 

4.  Cicatricial  oesophageal  stenosis.  Pin-hole  lumen.  White  linear  scars  seen  in 
perspective.  Recurrence  of  stenosis  following  ulceration  during  typhoid  fever.  Primary 
lesion,  burned  by  swallowing  lye  in  childhood,  14  years  previously.      Man  aged  21  years. 

5.  Bottom   of   diverticulum.     Mucosa   chronically   inflamed.      Man   aged    64  years. 

6.  Tuberculous  ulceration  posterior  oesophageal  wall,  simulating  decubitus  ulcer 
often  seen  in  typhoid  fever.  Tuberculous  lesions  in  this  location  are  somewhat  rare, 
though  stiU  more  rarel_v  are  they  diagnosticated.  Incidentally  this  figure  shows  the 
introitus  oesophageus  when  the  cricoid  cartilage  is  lifted  by  the  laryngeal  speculum.  The 
ulcer  is  on  the  edge  of  the  cricopharyngeal  fold. 

7.  Carcinoma  of  the  thoracic  oesophageal  wall  (left)  covered  with  normal  mucosa. 
The  lumen,  crescentic  in  shape,  is  pushed  to  the  right  and  almost  obliterated.  Man  aged 
60  years. 

8.  Carcinoma,  endoesophageal.  Woman  of  41  years,  referred  for  chronic  nasal  sinus 
disease.     (Esophageal  symptoms  slight  and  attributed  to  "globus  hystericus." 

9  and  12.  Fibroma  papillare,  attached  by  long  slender  fibrous  peduncle.  Disappeared 
into  the  oesophagus  at  times  after  swallowing.  Fig.  12  shows  the  attachment  within  the 
oesophagus  when  the  cricoid  cartilage  is  moved  forward  (instrument  not  shown).  Removed 
through  direct  laryngoscope.     Man  aged  36  years. 

10.  View  in  thoracic  oesophagus  showing  wounds  (direction  of  12  o'clock)  made  by 
blind  groping  with  a  coin  extractor  which  did  not  extract.     Boy  of  14  years. 

11.  Wound  in  oesophageal  wall  made  by  a  pin.     Woman  of  23  years. 

13.  Normal.  "Kink"  and  normal  spasm  of  the  oesophagus  at  the  hiatus,  probably 
more  a  preventive  of  regurgitation  than  the  cardia.  When  tube-mouth  is  moved  over  the 
opening  at  the  left,  the  hiatus  will  appear  as  a  tightly  puckered  rosette,  and  then  will 
open  to  gentle  pressure  with  the  oesophagoscopic  tube-mouth. 

14.  Perioesophageal  carcinoma  overlaid  with  normal  mucosa,  lumen  deviated  so  far 
to  right  as  to  be  out  of  view.  Diagnosis  correctly  made  upon  hardness  of  mass,  and  age  of 
the  patient.     Man  of  60  years. 

15.  Stomach  ulcer  (on  left  side  of  right  fold  in  the  view),  bed  showing  dark  after 
secretions  had  been  wiped  away.     Other  folds  normal.     Woman  aged  26  years. 

16.  Stomach.  Normal.  Fold  on  greater  curvature.  Dark  crimson  color.  Examined 
one  hour  after  drinking  milk.     Man  of  32  years. 

17.  Stomach.     Ulcerating  carcinoma.     Zone  of  hyperemia.     Man  of  46  years. 

18.  Stomach.     Same  patient.     Mulberry-like  nodule  at  another  portion  of  growth. 


PLATE  II 


^,  ^  o 

K^^tl 

B^^^^^l 

•)  <i  ® 

7                                      8                                      9 

O  O  «4^ 

10                                       II                                        12 

•  • 

13                                  \A 

(P    ^ 

16                                      17 

IS 

la 

Reproduction  of  water-color  drawings.     {Chevalier  Jackson.) 


LARYNX,  TRACHEA  AND  BRONCHI  465 

covered  with  a  pasty  coating  which  does  not  wipe  away.  Usually  food 
is  contained  in  the  dilatation  even  though  the  patient  has  been  on  liquids 
for  a  long  time.  When  the  bottom  of  the  dilatation  is  reached,  the 
hiatus  must  be  searched  for  and  will  be  readily  found  by  the  cesophagos- 
copist  who  is  familiar  with  its  appearance.  It  is  usually  a  tightly 
closed,  rosette-shaped  depression  with  radiating  folds.  Gentle  pressure 
with  the  distal  end  of  the  oesophagoscope  for  a  few  seconds  will  cause 
it  to  yield  and  the  oesophagoscope  will  glide  readily  through  into  the 
stomach.  The  abdominal  oesophagus  and  cardia  never  offer  any  resist- 
ance to  the  oesophagoscope  if  the  direction  of  the  axis  of  the  tube  Is 
made  to  correspond  with  that  of  the  abdominal  oesophagus,  as  explained 
under  (Esophagoscopy.  Radiography  is  a  valuable  aid  as  showing 
graphically  the  superjacent  oesophageal  dilatation;  and  radiography 
and  oesophagoscopy  should  go  hand  in  hand. 

Treatment  consists  in  dilatation  of  the  area  subject  to  spasm. 
Various  forms  of  dilating  water  bags  and  air  bags  have  been  used. 
They  are  efl&cient  if  they  can  be  placed  in  the  desired  location.  Many 
operators  have  found  that  the  dilating  bags  after  inflation  were  in  the 
diffuse  dilatation  and  not  in  the  spasmodically  stenosed  location  at  all. 
Other  observers  have  found  it  impossible  to  introduce  the  bags  through 
the  hiatus.  The  author's  preference  is  for  a  steel  instrument,  such  as 
that  of  Mosher.  This  can  be  put  in  place  with  great  accuracy  under 
ocular  guidance,  by  means  of  the  oesophagoscope  (//,  Fig.  198),  and 
the  spasmodically  stenosed  area  can  be  over-stretched  exactly  as  desired, 
preferably  very  sHghtly  beyond  the  normal  size.  There  can  be  no 
shifting  of  the  rigid  steel  instrument  during  dilatation. 

Cicatricial  stenosis  of  the  cesophagus  is,  in  most  instances,  due  to 
the  swallowing  of  corrosive  substances,  such  as  solutions  of  lye,  washing 
powders,  ammonia,  acids,  etc.  (Fig.  4,  Plate  II).  Less  common  are 
the  cicatrices  following  the  traumatism  of  foreign  bodies,  breaking 
down  of  gummata,  the  ulceration  of  lues  and  tuberculosis,  and  the  com- 
plicating mixed  infections.  Kyle  reports  a  shght  stenosis  following 
the  lodgment  of  a  tooth-plate  which  had  been  in  situ  in  the  oesophagus 
for  17  years  before  he  removed  it.  The  stenosis  was  subsequently  cured 
cesophagoscopically. 

The  diagnosis  can  be  made  in  a  few  minutes  by  oesophagoscopy 
which  gives  all  the  safety  and  precision  afforded  by  direct  vision.  The 
lumen  of  the  stenosis  may  be  found  to  be  a  mere  pin  hole  or  a  number 
of  millimeters  in  size.  In  some  instances  there  is  no  lumen,  the  lumen 
of  the  cesophagus  having  been  entirely  obliterated. 
30 


466  REGIONAL   SURGERY 

If  the  patient  is  in  a  serious  state  of  food  starvation,  an  immediate 
gastrostomy  should  be  done  because  any  form  of  treatment  requires 
time  to  produce  results,  and  these  results  are  more  quickly  obtained 
after  the  cure  of  the  chronic  oesophagitis  due  to  the  stagnation  of  food 
and  maceration  of  the  mucosa.  All  forms  of  oesophagitis  usually  dis- 
appear within  two  weeks  after  a  gastrostomy  if  no  food  is  given  by  the 
mouth.  Water  may  be  taken  occasionally  for  cleansing  the  oesophagus. 
Most  strictures  are  readily  dilated  by  means  of  the  fihform  bougie 


<- ^-CTP •>  ^ 

Fig.  252. — Filiform  silk- woven  bougie  on  steel  stem  for  dilatation  of  cicatricial  oesoph- 
ageal strictures  under  cesophagoscopic  guidance  of  the  eye.     {Jackson.) 

(Fig.  252)  passed  through  the  cesophagoscope.  If,  however,  there  are 
a  number  of  strictures  one  below  the  other  and  they  are  not  concentric 
with  each  other,  they  must  be  dilated  seriatim  from  above  downward. 
This  is  best  done  with  the  mechanical  dilator  (Fig.  253)  which  has  the 
advantage  of  dilating  at  its  extreme  point.  When  the  upper  stricture 
is  dilated  a  small  cesophagoscope  may  be  inserted  through  it  in  order 
to  find  the  lumen  of  the  next  stricture  below,  which  is  dilated  in  turn, 
and  so  on  downward  through  a  third  and  even  fourth  stricture.     Plum- 


CLOSED 


OPEN 
Fig.  253. — The  author's  oesophageal  divulsor  for  the  dilatation  of  cicatricial  oesoph- 
ageal strictures.     Its  greatest  divulsive  effect  is  at  the  point;  therefore,  it  can  be  used  to 
divulse  seriatim  a  series  of  eccentric  strictures  too  close  together  for  other  instruments  to 
be  entered. 

mer  and  Sippey  advocate  for  adult  patients  the  passage  of  bougies  over 
a  string  guide.  The  patient  swallows  a  string  a  day  or  two  beforehand 
and  when  the  lower  end  has  passed  through  the  stricture  and  through 
the  stomach  into  the  intestines  sufficiently  far  so  that  traction  can  be 
made  on  the  end  projecting  from  the  mouth,  an  olive  bougie  with  an 
eye  is  threaded  over  the  string.  Increasing  sizes  of  olives  follow. 
Mixter,  who  was  the  first  to  advocate  string  swallowing,  used  the  string 
as  a  saw  after  doing  a  gastrostomy  to  get  hold  of  the  lower  end. 


LARYNX,  TRACHEA  AND  BRONCHI 


467 


Diverticulum  of  the  (Esophagus. — Traction  diverticula,  which  are 
due  to  the  contraction  of  cicatrices  adherent  to  the  oesophageal  wall, 


Fig.  254. — Radiograph  showing  bismuth-tilled  pulsion  diverticulum  in  a  man  67 
years  of  age.  Diverticulum  (Fig.  255)  removed  by  Dr.  Otto  C.  Gaub  by  the  Gaub- 
Jackson  operation,  Fig.  256.      {Radiograph  made  by  Paiicoast.) 

are  usually  located  in  the  thoracic  oesophagus.  They  are  of  no  surgical 
importance  because  they  produce  no 
symptoms.  Pulsion  diverticula,  on  the 
contrary,  produce  most  marked  symp- 
toms and  soon  result  in  serious  inani- 
tion from  difficulty  in  swallowing.  They 
are  always  located  in  the  neck  and 
always  start  at  the  unsupported  oesoph- 
ageal wall  between  the  circular  and 
the  oblique  fibers  of  the  cricopharyngeus, 
as  demonstrated  by  Killian.  The  condi- 
tion constitutes  a  hernia  of  the  oesoph- 
agus. The  patients  usually  complain 
of  difficulty  in  swallowing,  cough  and 
expectoration  of  food,  and  a  gurghng 
sound  on  swallowing.     Pressure  on  the  side  of  the  neck  will  elicit  the 


Fig.  255. — Diverticulum  re- 
moved by  the  Gaub-Jackson  opera- 
tion, from  a  man  of  67  years. 


468 


REGIONAL   SURGERY 


gurgling  sound  if  the  mouth  is  held  open,  as  discovered  by  Boyce  on 
one  of  the  author's  cases.  The  diagnosis  is  readily  made  by  cesophagos- 
copy  and  by  a  bismuth  radiograph.  Radiography  after  a  bismuth 
meal  shows  the  shadow,  as  in  Fig.  254,  but  taken  alone  it  might  oc- 
casionally lead  to  serious  error,  as  shown  in  Fig.  256.  No  case  should 
be  operated  upon  until  after  both  radiographic  and  oesophagoscopic 
study.  Some  cases  have  a  more  or  less  strictured  cicatricial  subdiver- 
ticular  opening,  and  unless  this  is  divulsed,  cure  will  not  follow  excision 


Fig.  256. — Radiograph  showing  a  dilatation  simulating  a  pulsion  diverticulum.  A 
cicatricial  stricture  of  luetic  origin,  discovered  by  oesophagoscopy,  fails  to  show  because  it 
is  up  back  of  the  dilatation.  Oisophagoscopic  divulsion  with  the  bougies,  Fig.  252,  resulted 
in  perfect  cure.     {Author's  case.     Radiography  by  Dr.  Russell  H.  Boggs.) 

of  the  diverticulum.  Blind  methods  of  diagnosis,  by  bougie  and  labo- 
ratory methods  with  test  meals,  are  obsolete.  OEsophagoscopy,  which 
gives  the  absolute  certainty  of  ocular  inspection,  requires  but  a  mo- 
ment, and  is  done  without  any  anaesthetic,  general  or  local.  On  pass- 
ing the  cesophagoscope,  the  pouch  of  the  diverticulum  is  found  to  con- 
stitute a  continuation  of  the  pharynx.  The  subdiverticular  opening 
is  nowhere  visible  and  must  be  searched  for  along  the  anterior  wall. 


LARYNX,  TRACHEA  AND  BRONCHI  469 

When  found,  the  oesophagoscope  is  inserted  in  it  and  the  nature  of 
the  diverticulum  becomes  fully  demonstrated.  A  slanted-end  oesoph- 
agoscope or  the  oesophageal  speculum  is  best  for  this.  The  mucosa 
lining  the  diverticulum  is  practically  always  in  a  state  of  chronic 
oesophagitis  (Plate  II,  Fig.  5). 

The  treatment  consists  in  extirpation.  If  left  to  itself  the  diverticu- 
lum will  increase  in  size  until  the  pouch,  when  full  of  food,  compresses 
the  oesophagus  below  and  prevents  swallowing,  resulting  in  serious  or 
fatal  inanition.  Extirpation  looks,  in  the  radiograph  (which  shows  the 
diverticulum  distended  with  food),  to  be  a  very  easy  procedure.  When 
operated,  however,  the  diverticulum  must  necessarily  be  empty,  and 
in  its  collapsed  state  a  small  diverticulum  has  been  overlooked  by  the 
most  skilful  surgeons.  Partial  removal  fails  to  cure  symptoms  and  in- 
vites recurrence.  Removal  of  the  oesophageal  wall  has  caused  stenosis. 
To  prevent  these  possibilities,  as  well  as  to  expedite  the  operation,  the 
Gaub- Jackson  operation  is  now  used.  Its  technique  will  be  readily 
understood  from  the  schema  (Fig.  257).  The  external  part  of  this 
operation  is  described  under  the  head  of  external  oesophagotomy. 

External  Cervical  (Esophagotomy. — Insufflation  intratracheal  anaes- 
thesia should  always  be  used  for  this  operation  because  respiration  is 
very  apt  to  be  interfered  with,  either  by  traction  on  the  oesophagus  or 
by  adductor  spasm  of  the  vocal  cords  due  to  irritation  of  the  recurrent 
or  the  pneumogastric  nerves.  The  head  is  extended  and  the  left  side 
of  the  neck,  which  is  uppermost,  is  rendered  prominent  by  a  sand  bag. 
An  incision  is  made  along  the  anterior  edge  of  the  left  sternocleido- 
mastoid ridge.  The  deep  fascia  is  divided  and  the  muscle  is  drawn 
aside  along  with  the  blood-vessels  and  nerves.  The  thyroid  gland  is 
retracted  toward  the  median  line.  The  landmark  to  bear  in  mind  is 
the  cricoid  cartilage.  A  large  vertical  extent  of  wound  must  be  made 
and  must  be  kept  clean  and  dry  by  careful  hemostasis.  The  cricoid 
cartilage  and,  below  it,  the  rings  of  the  trachea  must  be  seen.  Pos- 
teriorly the  oesophagus  is  seen  as  a  thin  flat  fold  pressed  against  the 
cervical  vertebra.  If  it  is  desired  to  open  the  oesophagus,  the  latter  is 
drawn  out  with  silk  sutures  and  isolated  from  surrounding  structures 
with  gauze  pads  before  opening.  If  the  intention  is  the  amputation 
of  a  diverticulum,  the  oesophagoscopist  is  asked  to  push  out  the  diver- 
ticulum into  the  wound.  The  bottom  of  the  pouch  is  seized  with  for- 
ceps (Fig.  257).  Then  the  oesophagoscopist  inserts  his  oesophagoscope 
into  the  subdiverticular  lumen  of  the  oesophagus,  and  the  surgeon 
amputates  the  redundancy,  being  careful  not  to  make  undue  tension 


47° 


REGIONAL    SURGERY 


lest  there  be  a  scarcity  of  tissue  with  resultant  stricture.  The  surround- 
ing structures  are  thoroughly  bulwarked  by  inflammatory  adhesions. 
The  wound  in  the  oesophagus  may  be  united  in  three  layers,  the  mucosa 
first,  then  the  muscle  and  then  the  external  coat.  Or  any  form  of  in- 
vaginated  suture  may  be  used.  Supporting  sutures  are  inserted  wher- 
ever possible,  and  the  entire  external  wound  is  closed  with  the  exception 
of  a  small  drain  inserted  at  the  most  favorable  point.  The  drainage 
should  be  removed  as  soon  as  possible.     Feeding  should  be  by  soft 


Fig.  257. — Schema  showing  Gaub-Jackson  operation  for  excision  of  oesophageal 
diverticulum.  At  A,  the  cesophagoscope  is  represented  in  the  bottom  of  the  pouch  after 
the  surgeon  has  cut  down  to  where  he  can  feel  the  cesophagoscope.  Then  the  oesophagos- 
copist_  causes  the  pouch  to  protrude  as  shown  by  the  dotted  line  at  B.  After  the  surgeon 
has  dissected  the  sac  entirely  free  from  its  surroundings,  he  makes  traction  upon  the 
bottom  of  the  sac,  as  shown  at  H,  while  the  oesophagoscopist  inserts  the  cesophagoscope 
down  the  lumen  of  the  subdiverticular  oesophagus,  as  shown  at  C.  The  cesophagoscope 
now  occupies  the  lumen  the  patient  wiU  need  for  swallowing.  It  remains  for  the  surgeon 
to  amputate  the  redundancy,  without  risk  of  removing  any  of  the  normal  oesophageal 
wall,  or  risk  of  leaving  part  of  the  redundancj'  unremoved. 

rubber  tubes,  carefully  inserted.  Primary  union  is  usual.  Should  the 
wound  break  down,  a  free  drainage  tract  must  be  maintained  in  as 
cleanly  a  state  as  possible.  It  may  be  freely  irrigated  by  permitting 
the  patient  to  swallow  sterile  water  at  frequent  intervals.  Peroxide  of 
hydrogen  may  be  advantageously  added  to  the  water.  By  measuring 
and  subtracting  the  fluid  which  escapes  externally  from  the  total 
amount  given,  the  amount  of  fluid  swallowed  can  be  determined  (Otto 
C.  Gaub).  As  soon  as  the  fistulous  tract  becomes  covered  with  granula- 
tions, sterile  liquid  food  may  be  given,  followed  by  copious  draughts  of 


LARYNX,  TRACHEA  AND  BRONCHI 


471 


water  to  wash  leakage  from  the  tract.  While  leakage  is  usually  dis- 
couraging to  both  surgeon  and  patient,  it  is  really  a  beneficial  thing, 
bulwarking  against  recurrence  of  the  diverticulum  by  the  support  given 
by  the  inflammatory  tissue.  The  fistula  will  usually  close  spontane- 
ously in  two  or  three  weeks.  If  it  should  not,  curettage  should  be  used 
to  prevent  epithelialization  of  the  fistula. 

INFECTIVE  DISEASES  OF  THE  (ESOPHAGUS 

Pyogenic  infections  may  follow  the  trauma  of  foreign  bodies,  but 
unless  the  wall  is  perforated  and  the  infection  escapes  into  the  peri- 
oesophageal  tissues,  heahng  usually  takes  place  promptly.  The  best 
treatment  for  these  traumatic  infections  is  bismuth  subnitrate,  given 


^::^ 


Fig.  258. — Autoplastic  repair  of  the  pharynx  and  upper  oesophagus  with  submental 
flaps  after  partial  cesophagectomy  (and  laryngectomy).  The  flaps  are  turned  epidermal 
surface  inward.     The  turning  in  of  hair  bearing  epidermis  should  be  avoided.     {Jackson.) 

dry  on  the  tongue  in  small  doses  at  frequent  intervals,  with  the  occa- 
sional addition  of  a  little  calomel.  These  act  as  local  antiseptics  and 
have  remarkable  power  in  controlling  pyogenic  infections. 

Tuberculosis  of  the  oesophagus  is  relatively  rare  but  is  seen  in  two 
forms:  a  superficial  primary  lesion,  which  is  rare;  and  the  erosion 
through  of  a  mediastinal  tuberculous  lymph  node.  In  either  form 
recovery  is  the  rule,  if  the  patient's  general  condition  is  amenable  to 
treatment.  The  regular  antituberculous  regime  is  curative  and  local 
treatment  is  unnecessary. 

Syphilis  of  the  oesophagus,  while  not  common,  is  not  so  rare  as  was 
supposed  prior  to  the  days  of  oesophagoscopy.  It  may  occur  as  a 
mucous  plaque,  or  as  a  gummatous  or  ulcerative  tertiary  lesion.  In 
either  case  it  is  amenable  to  general  treatment.     In  extensive  ulcerative 


472  REGIONAL    SURGERY 

disease,  as  soon  as  healing  has  taken  place,  active  cesophagoscopic 
bouginage  must  be  undertaken  to  prevent  cicatricial  stenosis. 

TUMORS  OF  THE  (ESOPHAGUS 

Benign  tumors  of  the  oesophagus  are  quite  rare.  Tumors  of  in- 
flammatory origin,  not  true  neoplasms,  such  as  edematous  polypi  as- 
sociated with  other  lesions,  benign  or  mahgnant,  are  relatively  frequent. 
Granulomata  are  not  uncommon.  Angiomata,  papillomata  and  fibro- 
mata (Fig.  12,  Plate  H)  have  been  reported  by  a  number  of  observers. 
These  are  all  readily  removed  through  the  oesophagoscope  by  means 
of  forceps,  except  in  the  case  of  angiomata,  which  are  better  dealt 
with  by  the  galvano-cautery  or  by  radium  therapy. 

Malignant  Disease  of  the  (Esophagus. — Mahgnancy  occurs  most 
frequently  in  the  epithehomatous  form,  though  sarcoma  and  endo- 
theHoma  are  seen.  The  shghtest  difficulty  in  swallowing,  in  fact  the 
slightest  abnormal  sensation  in  swallowing,  should  be  considered  an 
indication  for  an  immediate  cesophagoscopy.  Unfortunately,  however, 
the  older  methods  of  diagnosis  were  so  very  unreliable  that  malignancy 
was  never  discovered  early  enough  to  offer  any  hope  of  cure.  The 
diagnosis  is  quickly  made  with  the  oesophagoscope  if  the  lesion  involve 
the  oesophageal  wall.  The  cesophagoscopic  picture  may  be  that  of 
normal  mucosa  covering  a  hard  infiltrated  mass,  with  asymmetrical 
inspiratory  enlargement  of  lumen  (Fig.  7,  Plate  n),but  usually  ulcera- 
tion and  fungation  are  present  (Fig.  8,  Plate  H).  The  removal  of  a 
specimen  for  biopsy  is  justified  in  any  case  and  an  ample  one  is  readily 
taken  with  the  forceps  shown  at  E,  in  Fig.  198.  Leucoplakia  has  been 
observed.^  In  other  cases  round  nodular  masses  grouped  in  mulberry- 
like  form,  either  dark  red  or  light  red  in  color,  are  seen.  (Edematous 
polypoid  masses  frequently  appear  in  the  later  stages. 

The  treatment  of  malignancy  in  the  "party- wall,"  occurring  as  a 
post-cricoidal  oesophageal  cancer,  is  best  extirpated  along  with  the  in- 
volved larynx  at  a  laryngectomy,  the  oesophageal  wall  being  afterward 
repaired  as  shown  in  Fig.  258.  Hairs  afterward  growing  from  the  inner 
surface  of  the  flaps,  in  men,  may  require  repeated  removal  with  the 
oesophageal  speculum.  In  men,  when  possible,  cervical  flaps  free  from 
hair  should  be  used  instead  of  submental  flaps. 

Intrathoracic  malignant  disease  of  the  oesophagus  is  less  amenable 
to  surgical  procedure,  but  Henry  Janeway  has  devised  an  operation 

1  Chevalier  Jackson.     Peroral  Endoscopy  and  Laryngeal  Surgery,  1914. 


LARYNX,  TRACHEA  AND  BRONCHI  473 

which  promises  success,  as  soon  as  the  necessary  early  diagnosis  can 
be  made.  The  wonderful  development  of  oesophagoscopy  without 
anaesthesia,  general  or  local,  without  pain,  and  of  only  a  few  minutes' 
duration,  now  favors  an  early  resort  to  oesophagoscopy  for  the 
necessary  early  diagnosis.  The  slightest  abnormality  in  swallowing 
calls  for  immediate  oesophagoscopy.  The  transthoracic  operations 
are  considered  in  another  section  of  this  work.  Inoperable  cases 
have  been  treated  with  excellent  results  by  radium  therapy,  though, 
so  far,  these  results  have  not  justified  their  use  in  any  case  deemed 
operable.  The  equivalent  of  about  100  mgm.  of  radium  element  is 
necessary.  It  is  placed  in  a  metal  capsule  covered  with  hard  rubber  in 
order  to  screen  out  the  alpha,  beta,  and  secondary  radiations.  The 
capsule  is  attached  to  a  hollow  metal  tube  by  means  of  a  silk  cord. 
This  is  passed  down  through  the  oesophagoscope  and  placed  accurately 
in  situ,  for  it  is  very  necessary  to  know  that  the  capsule  is  in  contact 
with  the  growth  and  not  with  any  normal  tissue.  When  certain  that 
the  capsule  will  remain  in  place,  the  rod  may  be  dispensed  with  and  the 
silk  cord  left  in  the  oesophagus  for  withdrawal.  As  a  rule,  however, 
it  is  better  to  leave  the  rod  in  situ.  The  radium  must  be  kept  in  posi- 
tion for  a  time  varying  from  half  an  hour  to  three  or  four  hours.  This 
dosage  must  be  varied  according  to  experience.  The  first  effect  noticed 
is  the  disappearance  of  the  inflammatory  condition  due  to  mixed  infec- 
tions. Later  the  lumen  enlarges,  swallowing  becomes  easier  and  pain 
becomes  less. 

In  any  case  of  cancer  of  the  oesophagus,  the  patient's  nutrition  must 
not  be  allowed  to  suffer.  The  necessity  for  gastrostomy  can  be  post- 
poned a  long  time  by  the  use  of  intubation  tubes  which  are  easily  placed 
through  the  oesophagoscope,  being  removed  about  once  a  week  for 
cleansing.  Under  no  circumstances  should  the  patient's  nutrition  be 
allowed  to  suffer.  If  intubation  of  the  oesophagus  is  not  available,  an 
early  gastrostomy  should  be  done,  long  before  the  patient  has  begun 
to  suffer  from  food  or  water  starvation. 


SECTION  XIX 

THE  THYROID 

By 

CHARLES  H.  MAYO,   A.   M.,   M.   D.,  LL.    D.,    F.   A.   C.   S. 

Rochester,  Minn. 

History. — The  diseases  of  the  thyroid,  especially  "simple  goiter," 
have  attracted  the  attention  of  the  medical  profession  for  many  years, 
but  it  is  only  within  a  comparatively  recent  period  that  hyperplasia  of 
the  gland  and  indeed  many  other  pathologic  conditions  of  the  organ 
have  been  recognized  as  surgical.  In  1786  Parry ^  described  exoph- 
thalmic goiter  with  sufficient  clearness  to  enable  its  recognition  to  be 
quite  perfectly  made.  He  was  preceded  by  Morgagni,^  who  gave  a 
fairly  good  description  of  its  characteristics.  Fourteen  years  later 
Flajani,^  though  apparently  unaware  of  Parry's  previous  work,  again 
called  the  attention  of  the  medical  profession  to  the  symptom-complex 
which  we  know  as  "exophthalmic  goiter."  However,  it  was  not  until 
1843,  when  Graves'*  pubHshed  the  lectures  which  he  had  been  giving 
since  1835,  that  the  description  was  accepted  and  the  term  "Graves' 
disease"  applied  thereto  by  EngHsh-speaking  physicians.  Three 
years  before  Graves'  publication,  but  five  years  after  Graves  first  be- 
gan lecturing  on  the  subject,  von  Basedow^  published  in  German  a  clear 
description  of  the  same  symptom-complex  which  was  later  named  in 
Germany  "Morbus  Basedowii." 

Charcot,^  von  Graefe,^  Stellwag,^  Marie, ^  Gunn,^"  Kocher,^^ 
Moebius^^  and  others  all  contributed  important  observations  to  the 
literature  concerning  the  various  types  of  thyroid  enlargement  and  the 
symptoms  therefrom,  up  to  1886. 

Since  1890,  the  Hterature  has  been  so  voluminous  and  so  varied  as 
to  make  a  critical  review  beyond  the  limits  of  the  present  article. 

Anatomy. — The  thyroid  is  somewhat  like  a  horseshoe  in  shape  and 
rests  on  the  trachea,  with  one  lobe  on  each  side,  connected  below  by 
the  isthmus  which  crosses  the  upper  tracheal  rings.  These  lobes  are 
about  2  in.  long,  being  smaller  at  the  upper  pole.  The  right  one  is 
usually  the  larger.  The  entire  weight  is  from  i  to  i^i  oz.  The  gland 
is  invested  by  a  thin  fibrous  capsule  which  divides  posteriorly,  one 

475 


476         .  REGIONAL   SURGERY 

portion  lining  the  posterior  and  inner  surface,  while  a  part  passes  to  the 
opposite  side  behind  the  oesophagus.  This  investment  explains  the  pro- 
duction of  pressure  from,  tumor  growths  on  both  of  these  structures  and 
the  occasional  appearance  of  tumors  of  the  thyroid  between  them. 
Fibrous  bands  also  unite  the  gland  to  the  trachea,  which  causes  the 
thyroid  to  move  with  it.  Trabeculae  of  connective  tissue  pass  into  the 
structure  of  the  gland,  subdivide  into  the  framework  for  the  alveoli  and 
small  vesiculae,  and  serve  as  a  skeleton  for  the  lymph  channels  which 
extend  throughout  the  gland.  The  lymph  channels  probably  perform 
the  function  of  excretory  ducts,  the  larger  number  of  them  apparently 
emptying  into  the  veins  of  the  gland.  The  blood  supply  of  the  thyroid, 
considering  its  size,  is  remarkable  for  its  extent  and  also  for  its  freedom 
of  anastomosis.  No  other  organ  in  the  human  body  is  so  well  provided. 
AU  the  blood  in  the  body  passes  through  the  gland  once  an  hour. as 
it  does  through  the  brain.  Tschuewski^^  has  shown  experimentally 
the  amount  of  blood  flowing  through  the  thyroid  per  100  gm.  weight  of 
the  organ  to  be  20  cc.  a  gram  per  minute.  He  further  shows  the  gland  to 
be  twenty-eight  times  as  vascular  as  the  head  and  five  and  one-half 
times  as  vascular  as  the  kidney. 

The  superior  thyroid  artery  from  the  external  carotid  supplies  the 
upper  pole  on  its  inner  side,  dividing  and  entering  the  capsule.  The 
inferior  thyroid  from  the  thyroid  axis  enters  the  capsule  below  at  the 
hilus.  Occasionally  this  artery  is  derived  directly  from  the  common 
carotid.  The  main  veins  are  the  superior,  middle  and  inferior,  although 
many  others  seem  to  develop  in  diseased  organs.  The  nerve  supply 
is  derived  from  the  sympathetic.  In  intimate  relation  with  the  inferior 
thyroid  artery  is  the  recurrent  laryngeal  nerve,  which  lies  in  the  space 
between  the  trachea  and  the  oesophagus,  and  is  so  often  affected  by 
pressure  of  tumors,  by  operation,  or  by  scar  tissue  as  to  cause  hoarse- 
ness. On  the  left  side  the  recurrent  laryngeal  is  usually  more  deeply 
set  and  not  in  such  close  relation  to  the  artery. 

The  single  anlage  of  the  thyroid  is  first  discernible  as  a  prominence 
in  the  ventral  wall  of  the  pharynx  between  the  first  and  second  pharyn- 
geal pouches.  This  invagination  of  the  ectoderm  becomes  constricted, 
the  hollow  stalk  of  the  vesicle  forming  the  thyroglossal  duct.  The 
opening  of  the  latter  is  soon  incorporated  into  the  anlage  of  the  tongue 
and  its  lumen  is  obliterated,  the  foramen  caecum  at  the  posterior  part 
of  the  tongue  marking  its  former  opening.  According  to  Gaskell,^^  the 
delivering  duct  of  the  thyroid  persists  in  a  number  of  the  invertebrate 
animals.     GaskelP^  believes  that  in  ammocoetes  the  organ  is  probably  a 


THE   THYROID  477 

sex  gland  delivering  into  the  genital  tract.  This  sex  relationship  is 
marked  throughout  all  animal  life.  Marine^^  has  shown  that  of  the 
five  varieties  of  epithehum  lining  the  endostyle  of  ammocoetes  only  one 
or  two  persist  in  the  true  thyroid  developed  thereform  in  the  adult 
animal.  The  anlage  of  the  thyroid  develops  into  a  broad  body  com- 
posed of  irregular  cords  of  cells  which  become  differentiated  into 
individual  groups  of  cells,  the  anlage  of  the.foUicles.  These  folHcles 
may  possess  a  lumen,  although  for  the  most  part  the  lumina  appear 
later  and  successively,  even  to  some  extent  forming  in  the  first  years  of 
childhood. 

Anomalies  of  development  are  not  unusual.  There  may  be  a  total 
absence  of  the  thyroid  or  the  persistence  of  a  rudimentary  type  of  gland, 
as  occurs  in  cretins.  A  portion  of  the  gland  may  persist  in  its  original 
location  at  the  base  of  the  tongue,  forming  a  "Ungual  thyroid."  During 
its  descent  into  the  neck,  portions  of  embryonic  thyroid  may  be  de- 
tached, forming  "aberrant  thyroids."  The  most  common  anomaly  is  a 
stringing  out  of  the  foetal  thyroid  by  entanglement  with  the  hyoid  bone 
in  its  development,  forming  the  "pyramidal  lobe."  Portions  of  the 
thyroglossal  duct  may  remain  patent  and  later  in  life  cause  "thyro- 
glossal  duct  cysts,"  due  to  the  activity  of  misplaced  and  uncontrolled 
embryonic  mucosa. 

Physiology. — The  thyroid  is  a  ductless  gland  or  a  gland  of  internal 
secretion.  Its  definite  function  is  still  an  unsettled  question.  Certain 
physiologic  facts  are  known.  Absence  of  the  thyroid,  either  natural  or 
experimental,  in  young  animals  markedly  retards  their  physical  and  men- 
tal development  and  inhibits  the  maturity  of  sex,  producing  the  con- 
dition known  as  cretinism.  Total  removal  of  the  gland  in  an  adult 
animal  causes  marked  mental  and  physical  deterioration,  resulting  in 
a  condition  parallel  to  that  known  in  man  as  myxcedema,  a  symptom- 
complex  due  to  thyreo-priva.  It  is  certain,  therefore,  that  the 
thyroid  plays  a  powerful  role  in  the  animal  metabolism.  Experimental 
hyperthyroidization  has  never  yet  proved  successful,  though  certain 
symptoms  of  toxaemia  are  easily  induced  by  feeding  with  thyroid. 

It  was  shown  by  Baumann'®  that  the  thyroid  contains  a  considerable 
amount  of  iodine  in  organic  combinations.  The  iodine  content  varies 
greatly  in  different  animals,  being  much  less  in  herbivorous  animals. 
It  has  been  shown  to  vary  with  the  amount  of  hyperplasia  present  in 
the  gland.  Iodine  medication  speedily  increases  the  iodine  content  of 
the  gland,  and  usually  reduces,  though  it  may  increase,  its  size. 

The   thyroid  is  physiologically  susceptible   to  various  influences. 


478  REGIONAL   SURGERY 

Its  size  is  increased  at  the  age  of  puberty  in  the  female,  so  much  so  that 
in  certain  parts  of  the  country  almost  all  girls  of  high-school  age  have 
somewhat  enlarged  thyroids.  These  enlargements  are  so  common  that 
they  must  be  considered  as  physiologic.  They  ordinarily  subside  after  a 
few  years.  The  gland  enlarges  with  menstruation  in  many  females, 
and  also  enlarges  from  various  factors  such  as  fright,  sexual  excite- 
ment, and  some  infectious  diseases.  In  old  age  the  gland  becomes 
atrophied. 

The  recent  work  of  Eppinger,  Falta  and  Rudinger^^  on  the  physiology 
of  the  thyroid  deserves  mention.  They  contend  that  internal  secre- 
tions of  the  thyroid,  the  pancreas  and  of  the  other  organs  of  the  chromaf- 
fin system  represent  a  series  of  interacting  inhibitory  and  excitatory 
influences.  For  the  details  of  this  work  the  reader  is  referred  to  the 
original  articles. 

Since  Baumann's^^  observations  an  enormous  amount  of  study  has 
been  put  on  the  relationship  of  the  iodin  content  of  the  thyroid  to  the 
physiologic  activity  of  the  gland  by  Oswald,^^  Marine,^^  Hunt,^°  Smith,^^ 
KendalP^  and  others.  Kendall  has  recently  pointed  out  this  relation- 
ship as  follows: 

"During  the  past  twenty  years,  investigation  has  firmly  established, 
among  other  things,  the  following  two  facts:  (i)  The  thyroid  contains 
some  substance  capable  of  producing  marked  physiologic  effects,  and 
(2)  iodin  is  a  constant  constituent  of  normal  and  pathologic  glands. 
These  two  facts  are  emphasized  because  most  of  the  controversies  con- 
cerning the  thyroid  have  arisen  from  attempts  to  explain  the  relation 
between  the  physiologic  activity  and  the  presence  of  iodin. 

"It  is  obvious  that  no  final  conclusions  could  be  arrived  at  until 
either  some  substance  possessing  physiologic  activity  had  been  isolated 
in  pure  form  and  shown  to  be  a  normal  constituent  of  the  gland,  or 
until  the  compound  containing  iodin  had  been  isolated  in  pure  form 
and  its  physiologic  activity  determined. 

"Last  December  (1914)  I  reported  the  separation  from  the  thyroid 
of  a  preparation  containing  60  per  cent,  of  iodin.  The  present  paper  is 
a  summary  of  the  results  thus  far  obtained.  In  brief,  the  compound 
containing  iodin,  the  presence  of  which  as  a  normal  constituent  of  the 
thyroid  was  foretold  by  Baumann  nineteen  years  ago,  has  been  iso- 
lated in  pure  crystalline  form,  and  further,  it  has  been  shown  that  this 
compound  is  the  substance  in  the  thyroid  which  is  responsible  for  the 
physiologic  activity  of  the  gland. 

"Previous  investigation  has  shown  that  the  compound  containing 


THE    THYROID 


479 


iodin  is  firmly  held  as  a  constituent  of  the  thyroid  proteins.  Hence  sep- 
aration of  this  compound  must  be  preceded  by  a  breaking  down  of  the 
proteins  into  the  simpler  constituents  of  which  they  are  composed, 
Baumann  attempted  this  hydrolysis,  using  lo  per  cent,  sulphuric  acid, 
but  no  satisfactory  cleavage  of  the  molecule  resulted.  The  hydrolysis 
which  has  been  successful  was  accomplished  with  sodium  hydroxid  in 
alcohol  as  a  medium  for  carrying  out  the  process. 

"A  large  number  of  compounds  are  obtained  by  this  splitting  up  of 
the  protein,  but  they  are  separated  into  two  groups  by  the  addition  of 


Fig.  259. — Compound  containing  60  per  cent,  of  iudin  isolated  from  "A"  in  pure 

cr>'stalline  form. 


acid.     Those  compounds  insoluble  in  acid  are  designated  Group  A,  and 
those  soluble  Group  B. 

"The  total  iodin  in  the  gland  is  found  to  be  divided  almost  equally 
between  the  two  groups.  By  further  hydrolysis  of  the  A  group  the 
compound  containing  iodin  has  been  separated  in  pure  crystalline  form. 
Its  exact  formula  cannot  now  be  stated,  but  it  appears  to  be  di-iodo-di- 
hydroxy-indol.  It  crystallizes  in  microscopic  needles  that  melt  around 
220  C.  It  is  very  insoluble  in  alcohol,  ether,  water,  acids  and  sodium 
carbonate.  Dilute  hydrochloric  acid  dissolves  i  part  in  about  200,000. 
It  is  readily  soluble  in  dilute  alkali  and  ammonia. 


480  REGIONAL   SURGERY 

"No  definite  substance  possessing  physiologic  activity  has  been 
isolated  from  the  B  group,  but  it  is  known  to  be  a  complex  mixture 
containing  amino-acids.  The  iodin  in  B  is  in  organic  combination,  but 
the  nucleus  to  which  it  is  attached  is  unknown. 

"The  thyroid  having  been  separated  into  several  different  constitu- 
ents, it  seemed  desirable  to  test  each  one  for  its  possible  physiologic 
activity.  It  was  found  that  the  typical  effects  of  administration  of 
desiccated  thyroid — a  rapid  increase  in  pulse  rate  and  vigor,  increase 
in  metaboHsm  with  loss  of  weight,  and  increase  in  nervous  irritability — 
are  all  produced  by  the  A  constituents. 

"The  next  step  showed  that  in  A,  containing  about  5  per  cent,  of 
ibdin,  the  effects  produced  are  directly  proportional  to  the  amount  of 
iodin  present.  And  finally,  in  the  purification  of  A  and  the  separation  of 
the  iodin  compound  in  crystalline  form,  the  same  typical  effects  were 
produced  through  all  the  various  stages  of  purity,  up  to  and  including 
the  crystalline  compound  containing  60  per  cent,  of  iodin. 

"In  testing  B  for  physiologic  activity,  it  was  found  that  no  apparent 
effects  are  produced  when  B  is  given  experimentally  to  a  normal  animal 
or  human  being,  but  that  a  considerable  degree  of  activity  is  manifest 
when  B  is  given  to  patients  suffering  from  cretinism,  myxedema  and 
certain  conditions  of  the  skin.  However,  no  toxic  effects  have  been 
in  produced  by  the  administration  of  B,  even  in  the  large  amount. 

"This  nontoxic  effect  of  B  is  in  strong  contrast  to  the  action  oi  A. 
Although  both  A  and  B  contain  iodin,  it  has  been  shown  that  the  tox- 
icity of  A  is  in  direct  proportion  to  its  iodin  content,  but  B  iodin  given 
in  equal  amount  produces  no  apparent  effect. 

"As  previous  investigators  have  pointed  out,  it  is  not  iodin,  per  se, 
that  is  necessary.  This  work  shows  that  it  is  the  iodized  indol  that  pro- 
duces the  physiologic  activity.  The  actual  amount  of  the  crystalline 
iodin  compound  necessary  to  produce  marked  effect  is  exceedingly  small. 
A  total  of  1 1  mg.  (one-sixth  grain) ,  given  in  divided  doses  during  a  period 
of  fourteen  days  to  a  cretin  weighing  40  pounds,  increased  the  pulse  rate 
from  90  to  140.  A  total  of  30  mg.  (one-half  grain),  given  in  divided 
doses  over  a  period  of  eighteen  days  to  a  woman  weighing  112  pounds, 
increased  the  pulse  rate  from  75  to  130.  Not  only  in  rate  but  also  in 
apparent  vigor  of  the  beat  the  cardiogram  of  a  heart,  after  administra- 
tion of  the  iodin  compound,  simulates  a  cardiogram  of  a  patient  with 
exophthalmic  goiter." 

Pathology. — Wilson^^  briefly  summarizes  the  pathology  of  the  thyroid 
as  follows: 


THE   THYROID 


481 


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REGIONAL    SURGERY 


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THE    THYROID 


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REGIONAL   SURGERY 


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Descriptive  diag- 
nosis: undifferenti- 
-ated    fcetal  adeno- 
ma. 
Histological  unit. 

Descriptive  diag- 
nosis:  fcetal 
thyroid.  _  Shape: 
symmetrical  or 

thyroid  shape. 

Histological  unit. 


Descriptive  diag- 
nosis: "normal" 
thyroid.  _  Shape: 
symmetrical  or 

thyroid  shape. 

Histological  unit. 


Descriptive  diag-  Q 
nosis:       "normal" 
andkfcetal  thyroid. 
jShape:  symmetrical 
or  thyroid  shape. 
Histological  units. 


[Descriptive  diag- 
nosis: hypertrophic 
colloid  thyroid  or 
_oiter.  Shape: 
symmetrical  or 

thyroid  shape. 
Histological  unit. 


Descriptive  diag- 
nosis: hypertrophic 
p  a  r  e  n  chymatous 
thyroid  or  goiter. 
Shape:  symmetri- 
cal or  thyroid 
shape. 

Histological  unit. 


Descriptive  diag- 
nosis: hypertrophic 
.colloid  parenchy- 
matous thyroid  or 
goiter.  Shape: 
symmetrical  or 

thyroid  shape. 

Histological  unit. 


Descriptive  diag- 
nosis: hypertrophic 
fcetal,  colloid  and 
parenchymatous 
^1  thyroid  or  goiter. 
Shape:  symmet- 
rical or  thyroid 
shape. 
Histological  units. 


Fig    •'69  — Symmetrical  or   thyroid-shaped   thyroids  'or  goiters.     {MacCarty's  Surg., 

Gyn.  ^  Obstet.) 


Undifferen- 
tiated foetal 
adenoma. 

Simple     ade- 
noma. /■ 


Colloid    ade-4 
noma. 


Hypertrophic 
colloid  and 

parenchymat- 
ous adenoma. 


Hypertrophic 
parenchymat- 
ous adenoma. 


Foetal  unit. 


Normal  unit. 


Colloid  unit. 


Colloid  and 
parenchymat- 
ous unit. 


Parenchyma  t- 
ous  unit. 


Fig.  270. — Asymmetrical  or  nodular  thyroids  or  goiters. 

Gyn.  &•  Obstet.) 


{MacCarty's  Surg., 


THE    THYROID  48$ 

"The  thyroid  is  a  congeries  of  a  great  number  of  groups  of  cells 
which  may  be  found  even  in  the  adult  in  any  stage  of  development  from 
masses  of  unarranged  embryonic  cells  (Wolfler's  rests)  through  tightly 
packed,  centrically  arranged  groups  of  embryonic  epithehal  cells,  to 
well-developed  follicles  lined  with  epithelium,  evidently  capable  of  se-. 
creting  into  the  well-marked  central  cavity.  With  such  a  great  variety 
in  the  stages  of  development  of  the  epithelium  of  the  gland  existing  even 
in  the  adult,  in  whom  there  are  no  symptoms  of  thyroid  change,  the 
pathologic  changes  produced  may  present  an  enormous  variety,  of 
which  the  following  are  the  more  important:" 

"  I.  The  simplest  change  which  we  find  appearing  upon  the  normal 
(resting)  thyroid  is  hyperaemia.  This  is  quickly  brought  about  by 
excitement  (sexual,  fear,  etc.)  and  is  usually  very  fleeting.  Yet  we  must 
remember  that  hyperaemia  always  materially  increases  the  index  both  of 
secretion  and  of  excretion  of  the  gland.' 

"2.  Associated  with  hyperaemia  may  be  hemorrhage,  which  may  be 
so  extensive  as  to  cause  sudden  and  great  enlargement  of  the  glandular 
tissue  and  frequently  results  in  secondary  cyst  formation." 

"3.  Acute  inflammation  of  the  thyroid  may  occur  as  the  result 
of  traumatism  or  as  an  incident  in  the  course  of  a  general  bacterial 
disease." 

^'4.  The  most  important  pathologic  changes  in  the  thyroid,  how- 
ever, as  related  to  goiter,  are  those  concerning  the  parenchyma.  The 
simplest  of  these  is  hypertrophy,  which  invariably  and  very  quickly 
follows  hyperaemia.  The  functionating  cells  of  the  parenchyma  become 
swollen  and  columnar  with  nuclei  approaching  their  free  extremities; 
the  acini  become  dilated  and  the  secretion  acquires  lowered  density, 
thus  more  readily  passing  into  the  circulation.  Simple  hypertrophy 
of  the  thyroid  may  result  temporarily  in  secretion  and  excretion 
beyond  physiologic  limits"  (Figs.  260,  261,  262). 

"5.  Progressive  hyperplasia  of  the  thyroid  consists  of  an  increase 
in  the  number  of  parenchyma  cells — which  are  also  almost  invariably 
hypertrophic — either  in  the  original  single  or  in  multiple  new  layers. 
Accompanying  this  is  an  overgrowth  or  stretching  of  the  stroma  or  an 
infolding  of  the  acinar  walls  with  papillomatous  growths  into  their 
cavities,  providing  basal  attachment  for  the  increased  number  of  cells. 
The  secretion  in  early  hyperplasia  has  always  a  low  density,  which, 
however,  rises  as  the  increased  function  is  prolonged.  !Many  thyroids 
in  cases  of  exophthalmic  goiter  show  every  portion  of  the  gland  in  an 
active  hyperplastic  condition,  all  evidence  of  embryonic  acini  having 


486  REGIONAL   SURGERY 

disappeared,  and  Wolfler's  rests  entirely  absent  or  perceptibly  crowded 
into  lesser  space  by  the  pressure  of  the  swollen  epithelium  of  the  acini. 
This  condition  is  par  excellence  that  associated  with  progressive  toxic 
symptoms  of  exophthalmic  goiter.  CHnically,  both  lobes  of  the  glands 
are  affected  and  the  enlargement  is  described  as  'bilaterally  sym- 
metric/ though  the  right  lobe  is  usually  larger  than  the  left"  (Figs.  263, 
264,  265.) 

"6.  Adenomatosis  of  the  thyroid  consists  of  a  diffuse  multiplication 
of  the  embryonic  acini  or  the  development  of  new  acini  from  Wolfler's 
rests.  Such  a  diffuse  increase  in  the  number  of  acini  should  be  sharply 
differentiated  from  the  formation  of  adenomas.  Adenomatosis  may 
be  associated  with  hypertrophy  or  h5^erplasia  of  the  contained  par- 
enchyma and  thus  be  the  condition  present  in  the  thyroids  in  cases 
which  develop  toxic  symptoms  late  in  the  course  of  simple  goiter. 
Sometimes,  however,  the  parenchymatous  cells  in  the  newly  formed 
acini  remain  cuboidal  and  without  hyperplasia." 

"7.  Regeneration  of  previously  atrophied  parenchyma  is  usually 
readily  differentiated  from  primary  parenchymatous  hypertrophy  and  hy- 
perplasia by  {a)  the  abundant  presence  of  atrophic  parenchyma  within 
large  acini,  {h)  the  development  of  numerous  new  acini  within  one  or 
more  portions  of  the  walls  of  the  old  large  colloid-filled  acini  and  which 
early  fill  with  dense  colloid,  and  (c)  the  development  of  multiple  layers 
of  relatively  small  parenchymatous  cells  within  the  large  colloid-filled 
acini  which  are  to  be  distinguished  from  primary  parenchymatous 
hypertrophy  and  hyperplasia  by  the  smaller  size  of  the  parenchymatous 
cells  and  the  absence  of  papillae." 

"8.  True  adenomas  of  the  thyroid  can  be  identified  only  when  they 
are  encapsulated.  Histologically,  they  are  of  two  types:  {a)  foetal 
adenomas,  in  which  the  parenchyma  is  of  true  foetal  type,  i.e.,  consisting 
either  of  cordons,  embryonic  tubules,  or  more  or  less  lumenless  groups  of 
spheroid  cells  or  of  combinations  of  these  group  units;  (&)  adult  ade- 
nomas, which  are  encapsulated  tumors  in  which  the  parenchyma  has 
taken  on  adult  characteristics,  that  is,  it  consists  largely  of  spheroid 
follicles  containing  lumina  lined  with  cells  of  adult  type.  The  tissue 
of  adult  adenomas  may  take  on  all  the  changes  which  have  been  noted 
in  the  thyroid  tissue  outside  the  encapsulated  tumors.  While  it 
may  be  true  that  adult  adenomas  develop  from  foetal  rests,  there  is 
insufficient  evidence  to  demonstrate  this  beyond  peradventure  and,  for 
both  pathologic  and  clinical  purposes,  it  is  best  sharply  to  differenti- 
ate the  two  on  the  lines  indicated  above." 


THE   THYROID  487 

"9.  Of  the  retrogressive  changes  in  the  thyroid,  retention  of  secre- 
tion is  the  most  common  and  approaches  nearest  to  the  normal  physio- 
logic state.  There  can  be  no  doubt  but  that  the  thyroid  is  not  only  an 
actively  secreting  organ,  but  that  it  has,  normally,  a  storage  function  as 
well.  It  is  impossible,  however,  to  say  what  constitutes  normal  stor- 
age function.  When,  however,  the  retention  of  secretion  has  reached 
the  stage  at  which  by  pressure,  by  enfeebled  circulation,  or  by  both,  the 
material  contained  in  the  glandular  acini  is  so  dense  that  the  index  of 
absorption  is  obviously  decreased  and,  when  the  parenchymal  cells 
lining  the  follicles  are  flattened  out  and  apparently  no  longer  secreting, 
there  can  be  no  doubt  that  we  have  a  pathologic  condition.  This  ex- 
treme retention  of  secretion  is  the  essential  element  in  the  formation  of 
the  so-called  colloid  or  simple  goiters.  Some  areas  in  such  thyroids 
occasionally  contain  sufficiently  active  parenchyma  that  it  may  take  on 
hyperaemia  or  hyperplasia  (regeneration)  and  permit  of  even  the  some- 
what rapid  absorption  of  long  quiescent  colloid.  Such  a  condition  ex- 
plains why  we  occasionally  have,  arising  late  in  the  history  of  old  col- 
loid goiters,  a  condition  of  acute  though  usually  mild  thyrotoxicosis" 
(Figs.  266,  267,  268). 

"  10.  Atrophy  of  the  parenchyma  of  the  thyroid  results,  as  else- 
where in  the  body,  from  overwork,  pressure,  and  lack  of  nutrition.  The 
cells,  becoming  flattened  from  pressure  of  retained  colloid  secretion,  may 
die  and  desquamate  from  the  acinar  walls.  This  condition  must  be 
differentiated,  however,  from  a  rapid  desquamation  and  disintegration 
of  the  parenchymal  cells  which  occasionally  occurs  in  the  course  of  acute 
hypertrophy  and  hyperplasia.  We  have  found  this  latter  condition  in 
a  few  cases  which  have  been  rapidly  fatal.  It  appears  to  be  exactly 
what  one  would  expect  in  the  case  of  an  intense  locally  acting  toxin." 

"11.  Of  the  terminal  degenerations,  aside  from  colloid — which  is 
often  overlooked — in  both  the  parenchyma  and  stroma,  hyaline,  amy- 
loid, and  calcareous  changes  are  not  uncommon.  These,  however, 
appear  to  have  no  clinical  significance  other  than  that  their  presence 
indicates  terminal  stages  of  an  old  process." 

"We  may  therefore  classify  the  histologic  conditions  met  with  in  the 
thyroid  as  follows : 

I.  Embryonic  (undeveloped)  thyroid. 

II.  Normal  (resting)  thyroid. 
III.  Vascular    changes. 

1.  Hyperaemia. 

2.  Hemorrhage  (including  resulting  cyst  formation). 


488  REGIONAL  SURGERY 

IV.  Inflammations. 
V.  Progressive  changes. 

1.  H3^ertrophy  (functional,  with  hyperasmia). 

2.  H}^erplasia  (" exophthalmic "  goiter) . 

3.  Adenomatosis  (multiplication  of  acini  without  encapsulation). 

4.  Regeneration  of  previously  atrophied  parenchyma. 
VI.  Retrogressive    changes. 

1.  Retention  of  secretion  (colloid  goiter). 

2.  Atrophy  (of  parenchyma). 

3.  Degenerations. 

(a)  Colloid  (of  parenchyma  and  stroma). 

(b)  Hyaline. 

(c)  Amyloid. 

(d)  Calcareous. 

(e)  Cystic. 
.  VII.  Tumors. 

1.  Benign. 

{a)  Foetal   adenomas   (encapsulated). 
(b)  Adult  adenomas  (encapsulated). 

2.  Malignant. 

(a)  Mesotheliomas. 

(b)  Carcinomas. 

(c)  Sarcomas. 

The  preceding  diagrams  illustrate  MacCarty's^^  hypothesis  of  the 
relationships  of  the  histologic  pictures  met  with  in  the  thyroid  (Fig.  270). 

EXOPHTHALMIC  GOITER 

Clinical  Symptoms. — Plummer^^  has  recently  called  attention  to 
the  fact  that  clinically  there  are  two  distinct  groups  of  toxic  goiters; 
one  exophthalmic  and  the  other  toxic  but  non-exophthalmic.  "Ex- 
ophthalmic goiter  is  a  definite  clinical  complex  always  associated  with 
hyperplasia  of  the  thyroid  and  it  should  be  sharply  distinguished  from 
the  constitutional  state  or  states  that  may  develop  with  non-hyper- 
plastic  goiter"  (Figs.  264,  267,  and  270). 

"For  the  purpose  of  quickly  presenting  the  clinical  pictures,  let  us 
note  the  parallelism  of  thyrotoxicosis  and  alcoholism  and  assume  that 
there  are  three  toxic  elements  in  the  thyroid  secretion,  one  damaging 


THE    THYROID  489 

chiefly  the  nervous  system,  one  the  circulatory  system,  and  the  other 
producing  exophthalmos.  In  exophthalmic  goiter  all  three  elements  are 
in  excess,  but  the  clinical  picture  is  dominated  by  a  nerve  toxin, 
although  in  individual  cases  the  circulatory  toxin  or  the  element 
producing  exophthalmos  may  seem  to  be  in  excess." 

"The  onset  of  exophthalmic  goiter,  is,  as  a  rule,  relatively  acute  and 
the  course  of  the  disease  fairly  definite.  The  clinical  picture  early  in 
the  history  is  that  of  a  toxin  acting  directly  on  the  more  vital  organs, 
more  notably  the  central  nervous  and  vascular  systems.  Later  it  is 
m.ade  more  complex  by  the  interaction  of  those  organs  whose  functions 
have  been  directly  disturbed  by  the  toxin.  The  order  of  onset  of  the 
more  important  symptoms  based  on  the  average  of  our  series  is  as 
follows:  (i)  cerebral  stimulation,  (2)  vasomotor  disturbances  of  the 
skin,  (3)  tremor,  (4)  mental  irritability,  (5)  tachycardia,  (6)  loss  of 
weight,  (7)  cardiac  insufl&ciency,  (8)  exophthalmos,  (9)  diarrhoea,  (10) 
vomiting,  (11)  mental  depression,  (12)  jaundice,  and  (13)  death." 

"If  the  average  course  of  the  intoxication  be  represented  by  a  curve 
the  greatest  height  is  reached  during  the  latter  half  of  the  first  year,  and 
then  suddenly  drops  to  the  twelfth  month.  In  many  instances  it  reaches 
the  normal  base  hne  during  the  next  six  months.  More  often  it  fluc- 
tuates with  periods  of  exacerbation  for  the  next  two  to  four  years. 
Secondary  symptoms  and  exophthalmos  may  remain,  but  the  active 
course  only  rarely  continues  over  four  years  without  distinct  intermis- 
sions. Compare  the  striking  resemblance  of  the  character,  order  of 
onset  and  course  of  this  train  of  symptoms  with  that  resulting  from  the 
heavy  use  of  alcohol  by  a  susceptible  individual  over  a  corresponding 
period  of  time.  Near  the  crest  of  the  curve  any  shock,  operation,  etc., 
that  treats  the  patient  to  'another  drink'  may  result  in  tremens  or 
death." 

"In  the  average  course  after  the  first  year  the  symptoms  that  may 
be  attributed  to  long-continued  intoxication  rather  than  to  a  high  de- 
gree of  acute  intoxication,  i.e.,  those  from  the  more  chronic  t>"pes  of 
heart,  liver,  and  kidney  degeneration,  enter  strikingly  into  the  chnical 
picture.  In  attempting  to  construct  a  composite  curve  we  find  that 
the  curves  for  those  symptoms  that  we  can  readily  attribute  to  a  high 
degree  of  immediate  intoxication  from  the  thyroid  gradually  drop  while 
the  curves  for  those  findings  attributable  to  a  long-continued  intoxica- 
tion of  a  lower  degree  gradually  rise." 

The  eye  symptoms  are  many.  Graefe^  noted  the  lagging  of  the 
upper  lid  in  following  the  movement  of  the  eyeball  upon  looking  down. 


490  REGIONAL   SURGERY 

Kocher^^  remarked  the  same  in  the  lower  lid  on  looking  up.  Stellwag^ 
noted  the  staring  without  winking  for  long  intervals. 

Dalrymple^''  remarked  the  widerung  of  the  palpebral  fissure.  Moe- 
bius^^  discovered  the  diplopia  with  near  vision  in  extreme  exophthal- 
mos. Landstrom^^  showed  the  exophthalmos  to  be  due  to  effects  of  the 
sympathetic  upon  the  non-striated  muscles  of  the  orbit  which  support 
the  globe  against  the  anterior  supporting  capsule  and  against  which  the 
voluntary  muscles  of  the  eyeball  exert  their  pull. 

Kocher^^  asserts  that  a  marked  lymphocytosis  is  characteristic  of 
exophthalmic  goiter.  Our  examinations  show  that,  while  this  is  true  in 
many  cases,  it  is  not  a  constant  finding  and  also  that  this  condition 
of  the  blood  is  not  infrequently  met  with  in  atoxic  and  in  toxic-non- 
exophthalmic  goiter. 

Pathology. — Wilson^°  has  shown  that  "not  only  is  there  a  constant 
association  of  primary  parenchymatous  hypertrophy  and  hyperplasia  of 
the  thyroid  with  exophthalmic  goiter,  but  that  further  both  the  clin- 
ical stage  and  the  clinical  severity  of  the  disease  may  be  estimated  froni 
the  stage  and  severity  of  the  pathologic  changes.  Thus  the  average 
ages  of  patients  with  early  primary  parenchymatous  hjrpertrophy  and 
hyperplasia  (Figs.  260,  261  and  262)  is  25  years  at  the  time  of  operation, 
while  they  have  had  their  symptoms  for  0.3  years.  The  corresponding 
figures  for  patients  whose  thyroids  show  advanced  primary  parenchy- 
matous hypertrophy  and  hyperplasia  (Figs.  263,  264  and  265)  is  31.7 
years  and  0.9  year  respectively,  while  for  those  patients  whose  thyroids 
show  regressing  primary  parenchymatous  hypertrophy  and  hyperplasia 
(Figs.  266,  267  and  268),  the  corresponding  periods  are  40.7  and  3.5 
years  respectively."  While  various  toxines  may  cause  degeneration  of 
the  essential  organs,  i.e.,  heart,  liver,  kidneys,  etc.,  the  toxin  causing 
the  symptom-complex  which  we  designate  thyrotoxicosis  must  be  asso- 
ciated with  definite  pathologic  changes  in  the  thyroid,  for  example, 
hypertrophy,  hyperplasia,  etc.,  in  order  to  prove  its  origin  therein. 

Treatment. — Some  cases  of  mild  exophthalmic  goiter  recover  spon- 
taneously, others  yield  to  careful  hygienic  treatment,  which  consists 
essentially  of  rest,  quiet,  mild  exercise  in  the  open  air,  reduced  nitrog- 
enous diet,  etc.  Specific  medication  for  exophthalmic  goiter  has  been 
largely  based  on  the  assumption  that  the  symptoms  are  due  to  the  ab- 
sorption of  a  toxin  from  the  gland  and  efforts  have  been  made  to  neu- 
tralize the  toxin  or  to  immunize  the  patient  against  its  effect.  The  milk 
(evaporated  milk — Rudigen's)  or  the  serum  of  thyroidectomized  goats 
used  by  Moebius^^  administered  internally  has  not  met  the  expecta- 


THE   THYROID  49 I 

tions  of  its  originator.  The  cytotoxic  serum  prepared  by  Beebe  and 
Rogers^-  after  the  plan  of  Kocher  has  been  more  successful  in  the- early 
stage  of  hyperthyroidism,  though  it  is  uncertain  in  its  results  even 
in  the  hands  of  its  originators.  The  mortality  under  this  treatment 
is  higher  in  the  cases  of  true  exophthalmic  goiter  than  under  com 
bined  medical  and  surgical  methods.  By  cytolysis  it  should  and  does 
make  the  thyrotoxic  goiter  worse. 

The  administration  of  iodin  both  internally  and  externally  is  one  of 
the  oldest  forms  of  medical  treatment  for  goiter.  Clinically,  while  it 
often  acts  well,  especially  in  the  oedematous  goiters  of  young  people,  it 
frequently  makes  the  condition  worse  (especially  is  this  true  of  exoph- 
thalmic goiter)  and  our  data  show  that  rules  for  its  proper  administra- 
tion are  still  undetermined.  Its  use  in  patients  between  the  ages  of  35 
and  60,  suffering  from  goiter  of  long-standing  seems  to  cause  an  over- 
stimulation with  rapid  degeneration  and  thyrotoxic  symptoms  causing 
degeneration  of  heart,  kidneys,  etc.  In  relation  to  the  surgical  treat- 
ment of  exophthalmic  goiter  of  severe  intoxication,  it  must  constantly 
be  borne  in  mind  that  we  are  dealing  with  a  chronic  disease  regularly 
presenting  improvement  followed  by  exacerbation  of  symptoms. 
In  the  severe  cases  growing  worse,  operation  must  not  be  performed. 
These  cases  are  for  a  time  medical  and  emergency  surgery  is  not 
indicated. 

As  a  preparation  for  thyroidectomy  in  severe  cases  of  hyperthy- 
roidism, the  use  of  the  Rontgen  ray  will  sometimes  cause  a  [temporary 
amelioration  of  the  more  severe  symptoms.  In  the  preparation  of 
very  serious  cases  of  this  type  the  injection  of  i,  2  or  3  dr.  of  boiling 
water  (Porter's^^  method)  into  a  lobe  of  the  gland  acts  favorably  in 
improving  the  condition  of  the  patient  so  that  a  Ugation  may  be 
accomplished  which  will  permit  the  ultimate  removal  of  a  portion  of 
the  gland. 

Operative  Treatment. — Ligation. — The  earliest  ligation  of  vessels  for 
the  relief  of  goiter  is  credited  to  Woliler.^'  Our  experience  with  this 
procedure  covers  more  than  20  years  and  about  1000  operations.  With 
the  results  obtained  by  this  method  we  consider  that  the  ligation  of 
vessels  and  at  times  of  a  portion  of  the  gland  seems  indicated  in  certain 
cases.  First,  in  those  patients  suffering  from  mild  symptoms  of  hyper- 
thyroidism which  are  hardly  severe  enough  to  warrant  a  thyroidectomy, 
the  ligation  of  the  vessels  will  often  produce  a  cure  in  a  few  weeks  with 
but  little  risk  and  without  the  necessity  of  special  medication.  Second, 
ligation  is  indicated  in  that  large  group  of  patients  having  acute,  severe 


492  REGIONAL    SURGERY 

exophthalmic  goiters  and  in  the  chronic  and  very  sick  patients,  who, 
having  exhausted  all  forms  of  treatment,  are  now  suffering  from  various 
secondary  symptoms.  Ligation  is  also  of  particular  value  in  those 
cases  of  marked  pulsation  and  thrill  of  the  thyroid  arteries  associated 
with  dilatation  of  the  heart  and  loss  of  weight.  The  relative  safety  of 
ligation  as  compared  with  thyroidectomy  may  lead  the  operator  to 
accept  as  surgical  risks  patients  so  far  advanced  in  the  disease  as  to 
have  but  little  prospect  of  cure.  The  gain  in  these  cases  is  almost 
marvelous.  Increase  in  weight  averages  about  22  pounds  in  four  months 
with  great  improvement  in  the  nervous  and  vascular  systems.  Thy- 
roidectomy is  advised  at  that  time  as  severe  cases  may  relapse  at  a 
later  period;  some,  however,  remain  improved  after  many  years. 
Should  the  condition  recur  before  a  partial  thyroidectomy  is  made  or 
should  a  severe  relapse  occur  after  partial  extirpation,  the  inferior 
thyroid  artery  should  be  Ugated  or  more  gland  removed,  or  both. 

AfKEsthetic. — The  anaesthetic  of  choice  is  ether,  as  for  other  general 
surgical  operations.  It  acts  well  in  simple  goiters  and  also  in  the 
majority  of  cases  of  hyperthyroidism.  By  reason  of  complications,  dis- 
ease of  the  kidneys,  heart,  or  lungs,  tracheal  pressure  or  high  blood 
pressure,  a  local  anaesthetic  may  be  indicated.  In  some  cases  it  is 
advisable  to  secure  the  benefits  of  combined  anaesthesia,  following  the 
general  plan  of  Crile,^^  by  the  injection  of  0.5  per  cent,  novocain  with 
adrenaHn  followed  by  a  light  general  anaesthetic.  Novocain  is  about 
one-eighth  as  toxic  as  cocaine  and  is  used  freely  in  the  line  of  proposed 
incision,  also  in  the  areas  of  nerve  distribution.  In  using  ether  it  is 
advisable  to  give  the  patient  3^^ 20  gr-  of  atropin  and  a  small  quantity  of 
morphin  one-half  hour  before  the  operation.  The  atropin  keeps  the 
pharynx  and  trachea  dry.  In  very  severe  cases  of  hyperthyroidism  the 
giving  of  )^oo  gr.  of  scopolamin  with  }i  gr.  of  morphin  one  hour  before 
operation  does  much  to  quiet  the  apprehensiveness  of  the  individual. 
Some  individuals  have  an  idiosyncrasy  for  scopolamin  which  may  be 
evidenced  by  pallor,  delirium,  etc.,  soon  after  administration.  In  such 
cases  the  drug  should  be  discontinued  and  the  operation  postponed  for 
24  hours. 

Operation. — In  ligating  the  blood  supply  of  the  gland  the  vessels 
of  the  superior  group  are  chosen  because  of  their  accessibility.  The 
inferior  thyroid  vessels  are  usually  ligated  in  cases  where  a  serious 
relapse  occurs  between  the  ligation  of  the  superior  vessels  and  the 
proposed  thyroidectomy.  The  transverse  incision  across  the  center  of 
the  thyroid  cartilage  is  employed  for  ligation  of  the  superior  vessels, 


THE    THYROID  493 

as  here  there  is  freedom  from  the  possibility  of  nerve-injury.  The 
anterior  border  of  the  sterno-mastoid  muscle  is  exposed  and  drawn 
outward,  clearing  the  outer  edge  of  the  omo-hyoid,  which  is  drawn  in- 
ward. This  brings  into  view  the  upper  pole  of  the  thyroid.  The 
ligature  is  placed  at  the  pole  or  slightly  on  the  gland  and  includes  sym- 
pathetic nerves,  arteries  and  veins.  This  prevents  the  reversal  of  cir- 
culation in  one  of  the  large  branches  of  anastomosis  with  the  inferior 
which  occurs  when  the  vessel  is  ligated  higher  up.  One  or  both  sides 
are  ligated  at  the  same  time,  according  to  the  conditions  and  the  neces- 
sities of  the  case.  In  the  more  serious  cases,  the  vessels  of  the  left  upper 
pole  are  Hgated  and  if  a  severe  reaction  follows,  the  right  upper  vessels 
are  ligated  from  five  to  seven  days  later.  If  the  reaction  is  not  marked, 
the  right  lobe,  isthmus  and  inner  border  of  the  left  lobe  (about  three- 
fifths  of  the  gland)  are  removed  at  the  second  operation.  When  it  is 
necessary  to  ligate  the  inferior  thyroid  artery,  it  is  exposed  by  a  trans- 
verse incision  with  a  natural  curve,  then  separating  between  the  lower 
division  of  the  sterno-mastoid  muscle,  the  omohyoid  is  drawn  to  the 
outer  side,  the  gland  is  exposed  and  elevated.  In  other  words,  the 
thyroid  artery  is  located  by  palpation,  exposed  and  ligated. 

OPERATIONS  ON  THE  THYROID 

Ligation  of  the  Inferior  Thyroid  Artery. — DeQuervain  recommends 
that  the  inferior  thyroid  artery  be  tied  external  to  the  fibrous  capsule 
of  the  gland.  Through  Kocher's  collar  incision  expose  the  inner 
margin  of  the  sterno-mastoid  and  retract  it  gently  outward.  ]Make  a 
vertical  i-in.  incision  through  the  external  fascia  of  the  sternohyoid 
and  retract  this  fascia  outward  with  the  sterno-mastoid.  It  is  now 
easy  to  penetrate  the  loose  connective  tissue  until  the  carotid  packet  is 
reached.  Palpate  the  carotid  tubercle  on  the  transverse  process  of  the 
sixth  cervical  vertebra;  about  %  in.  below  this,  one  can  feel  the  inferior 
thyroid  artery  immediately  to  the  inner  side  of  the  carotid  packet. 
DeQuervain  ties  the  inferior  artery  as  one  of  the  first  steps  in  almost  any 
operation  for  goiter. 

Thyroidectomy.^In  severe  cases  of  hyperthyroidism,  in  acute 
attacks  and  in  relapses  or  exacerbations,  the  condition  should  be  con- 
sidered medical  until  improvement  takes  place.  In  case  of  relapse 
after  a  primary  right  thyroidectomy,  the  left  upper  pole  is  ligated; 
this  operation  is  followed  by  removal  of  one-half  of  the  remaining  lobe 
after  improvement  occurs.     The  majority  of  patients  having  exoph- 


494 


REGIONAL   SURGERY 


thalmic  goiter  may  be  operated  on  when  they  come  to  the  surgeon  by 
the  removal  of  one  lobe  and  the  isthmus,  approximating  three-fifths  of 
the  gland.  The  exophthalmic  goiter  case  with  unilateral  thyroid 
enlargement  is  a  safe  one  for  the  extirpation  of  the  offending  lobe. 
One  of  the  great  dangers  of  the  operation  is  from  myocardial  change 


Fig.   271. — E.xposure  of  anterior  muscles,  cutting  of  stcrno-hyoid. 


usually  shown  by  uneven  tension  and  irregularity  in  the  pulse.  No 
patient  should  be  operated  on  radically  whose  pulse  cannot  be  counted 
continuously  because  of  uneven  tension.  Gastric  crisis  or  diarrhoea 
should  also  lead  to  postponement  of  operation.  Ascites  and  oedema 
of  feet  and  hands  are   contraindications,  and  such  cases    should  be 


THE  THYROID 


495 


placed   under   medical   care  for  a  time.     In  most    instances  all   the 
foregoing  contraindications  may  be  overcome. 

Extirpation  of  the  gland  or  resection  is  made  by  a  transverse  incision, 
passing  from  one  external  jugular  veinUo  the  other  in  a  natural  skin- 
crease  low  in  the  neck.     The  skin  and  platysma  muscle  are  lifted  up- 


FlG. 


-Opening  lateral  thyroid  fibrous  capsule. 


ward  as  a  single  flap,  exposing  the  general  outUne  of  the  gland,  which 
is  now  brought  into  view  by  dividing  vertically  between  the  sternohyoid 
and  thyroid  muscles  (Fig.  271).  The  true  capsule  of  the  gland  is  recog- 
nized as  the  one  containing  the  blood-vessels;  false  or  fibrous  capsules  do 
not  have  them  (Fig.  272).  Usually  the  lobe  to  be  removed  can  be  elevated 
between  these  muscles  as  they  are  stretched,  but  in  large  goiters  and  in 


496 


liEGIONAL   SURGERY 


exophthalmic  goiters,  it  often  becomes  necessary  to  cut  the  muscles  on 
one  side,  rarely  on  both.  The  muscles  should  be  cut  between  two  for- 
ceps which  are  placed  near  their  upper  ends,  as  this  preserves  the  body 
of  the  muscle  with  its  nerve-supply  and  breaks  the  line  of  penetrating 
muscle-moved  scar  so  disfiguring  after  some  operations.     The  lobe  to 


Fig.  273. — Elevation  of  thyroid  gland. 

be  removed  is  now  elevated  and  its  vessels  caught  and  cut  between  artery 
forceps,  many  being  applied.  The  forceps  are  so  appHed  as  to  skim  the 
lateral  and  posterior  surface  of  the  capsule  of  the  gland,  securing  as 
much  capsule  and  as  Uttle  of  the  surface  of  the  gland  as  possible  (Fig. 
273).  This  method  seems  preferable  to  the  immediate  appHcation  of 
double  ligatures  unless  the  number  of  forceps  which  it  is  necessary  to 


THE   THYROID 


497 


use  becomes  a  hindrance.  The  high  division  of  muscle  gives  ready  ac- 
cess to  the  superior  thyroid  artery  which,  after  being  divided,  permits 
the  rotation  of  the  lobe  across  the  trachea,  where  it  is  usually  separated 


^M 

HMH 

H 

^H 

Piy'''^^i 

^H 

^f 

,,/■'■ 

^M 

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k 

) 

External  Jugular    /- 

_ 

Sterno-'K\joid  M.''  ' 

terno-thxjroid  M 

^ 

mt3^^ 

••A 

#' ' 

Fig.   274. — Suture  oi  iniisclt-s,  (Iruiiuige  ami  closure  ot  llap. 


at  the  merging  of  the  isthmus  into  the  left  lobe  unless  removal  of  part 
of  that  lobe  is  desirable.  In  very  large  goiters  causing  tracheal  pressure 
it  is  often  advisable  to  divide  the  left  sternohyoids  as  well  as  to  free  the 
trachea  by  dividing  the  isthmus  of  the  gland,  the  central  portion  of  the 
32 


498  REGIONAL   SURGERY 

thyroid  being  removed  by  turning  the  lobes  outward.  This  operation 
is  somewhat  more  bloody,  but  quite  safe,  as  the  trachea  is  exposed  early. 
Catgut  is  efficient  suture  material.  Silk  is  best  when  many  Hgatures 
are  required,  since  they  are  rapidly  encapsulated  (Fig.  274).  A  few 
cases  of  adenoma  can  be  closed  without  drainage  after  filling  the  cavity 
with  salt  solution. 

In  most  cases,  tubular  drainage  is  employed  for  24  hours,  except 
in  large  substernal  goiters,  when  the  drain  is  removed  within  a  few 
hours  in  order  that  the  organization  of  the  early  blood-clot  may  occur 
to  aid  the  primary  closure  of  the  large  cavity.  Fortunately  the  major- 
ity of  large  substernal  goiters  are  of  the  encapsulated  adenoma  type  and 
permit  of  enucleation  within  the  thin  fibrous  investment. 

To  prevent  tetany,  the  epithelial  or  parathyroid  glands  must  be 
avoided  in  the  course  of  an  operation  and  preserved  even  if  it  be  neces- 
sary to  replace  accidentally  separated  ones  beneath  the  capsule  of  the 
thyroid  at  the  pole  of  the  gland.  Such  areas  must  be  free  from  bleeding 
to  insure  growth  of  the  graft.  These  bodies,  four  in  number  (two  on 
each  side),  are  known  to  be  occasionally  injured  by  hemorrhages  into 
them  at  birth,  so  it  is  impossible  to  say  whether  or  not  the  parathyroid 
bodies  are  all  present  and  whether  or  not  the  one  or  two  that  we  may 
injure  are  the  only  ones  existing.  It  is  advisable,  therefore,  to  keep  in 
front  of  the  posterior  capsule  or  very  close  to  it  in  extirpating  the  dis- 
eased portion  of  the  thyroid  and  not  to  remove  any  small  gland-like 
structures,  especially  in  those  cases  in  which  both  lobes  are  operated  on. 
Those  surgeons  whose  patients  have  had  tetany  following  operations  for 
goiter  have  apparently  removed  the  lateral  lobes  of  the  thyroid  and 
left  an  isolated  bit  of  the  isthmus  without  blood  supply  or  venous  return. 
Even  if  the  parathjToids  were  not  removed  their  circulation  was  im- 
paired. In  such  cases  there  has  been  both  thyroid  and  parathyroid 
deficiency.  The  cases  reported  have  usually  recovered  after  a  tedious 
convalescence  and  in  spite  of  much  experimentation. 

The  association  of  a  diseased  and  especially  an  enlarged  thymus 
with  the  goiter  in  cases  of  hyperthyroidism  is  claimed  by  some.  In 
our  experience,  it  is  not  a  constant  finding,  yet  a  large  thymus  caus- 
ing tracheal  pressure  may  seriously  complicate  the  operation  of  thy- 
roidectomy. 

In  the  early  development  of  surgery,  operations  on  exophthalmic 
goiters  were  delayed  until  serious  complications  arose  in  the  heart, 
kidneys  or  nervous  system.  This  led  to  a  high  mortality,  which  natu- 
rally deterred  physicians  from  sending  patients  to  surgeons  for  early 


THE   THYROID 


499 


operation.  The  greater  the  delay  the  greater  the  mortahty — henceja 
surgical  vicious  circle.  The  average  mortality  of  operations  on  ad- 
vanced cases  was  25  per  cent.  The  mortality  at  present  varies  from  i 
to  3  per  cent.  This  great  reduction  in  mortality  is  probably  due  less 
to  operative  skill  and  technique  than  to  better  judgment  as  to  the  time 
and  extent  of  the  operative  procedure  instituted,  as  well  as  to  the  skilled 
use  and  rational  choice  of  an  anaesthetic.  The  various  causes  of  mor- 
tality are  hyperthyroidism,  embolism,  pneumonia,  hemorrhage,  sepsis, 
etc.     About  75  per  cent,  of  cases  of  hyperthyroidism  are  cured  of  such 


Fig.  275. — Toxic-non-exophthalmic  goiter.     CHnical  Group  i. 


symptoms  as  are  preventive  of  good  health.  All  who  survive  are  im- 
proved, many  have  permanent  changes  in  heart,  kidneys  and  vessels 
secondary  to  the  toxaemia  from  hyperplasia  or  degeneration  of  goiter. 
Some  degree  of  relapse  occurs  in  about  10  per  cent,  of  cases.  In  about 
5  per  cent,  of  these  it  is  advisable  to  remove  more  gland. 

Patients  with  severe  exophthalmos  when  operated  on  late  may  still 
have  this,  as  about  the  only  symptom  remaining  after  operation  on  the 
gland.  In  some  cases  we  have  reduced  this  prominence  by  removing 
the  superior  and  middle  cervical  sympathetic  ganglia  on  one  or  both 


500 


REGIONAL   SURGERY 


sides  of  the  neck,  the  old  operation  of  Jaboulay^^  and  Jonnesco^^  for  the 
reUef  of  exophthalmic  goiter. 

TOXIC-NON-EXOPHTHALMIC  GOITERS 

Symptoms. — Plummer-^  divides  the  intoxications  from  non-h5^er- 
plastic  goiter  into  two  merging  groups:  (i)  a  group  in  which  the  cardiac 
toxin  predominates,  in  which  the  clinical  picture  closely  resembles  and 
in  many  instances  cannot  be  differentiated  from  the  cardiovascular 
complex  resulting  from  alcohoHc,  luetic,  septic,  and  other  well-known 
toxins  (Fig.  275);  (2)  a  group  more  closely  approaching  the  picture  of 


. 

r- 

^^Hpg^_  .^"^ 

i 

^K  '^'  i 

f 

'^fnMHf 

^KKSa . 

™^^^Z^3B 

'iVii'S 

-  fl|^^ 

3-15-07 

^^^^HP 

■  ^f^^^ 

Fig.  276. — Toxic  non-exophthalmic  goiter.     Chnical  group  2. 

Graves'  disease  and  including  the  cases  that  have  been  erroneously  so 
diagnosticated  by  the  mass  of  the  profession  (Fig.  276). 

"Patients  coming  under  observation  with  non-hyperplastic- toxic 
goiter  give  a  history  of  having  first  noted  the  goiter  at  the  average  age 
of  22  years,  and  the  evidence  of  intoxication  at  the  average  age  of  36.5 
years.  The  correponding  ages  for  hyperplastic  goiter  are  respectively 
32  and  32.9  years." 

"The  average  lapse  of  time  between  the  appearance  of  non-hyper- 
plastic goiter  and  toxic  symptoms  is  14.5  years.  That  the  patient  comes 
under  observation  three  years  later  indicates  that  the  onset  is  usually 


THE    THYROID 


501 


insidious.  Nervousness,  tremor,  loss  of  strength  and  weight,  as  a  rule, 
develop  slowly,  but  may  appear  suddenly  long  before  definite  evidence 
of  myocardial  damage.  The  administration  of  iodine  may  cause  the 
sudden  appearance  of  those  symptoms  with  myocardial  insufficiency 
much  as  they  might  follow  the  prolonged  drinking  bout  of  an  old  toper 
who  had  not  previously  shown  decided  evidence  of  chronic  alcoholism. 
In  some  cases  the  chnical  aspect,  as  noted  above,  closely  approaches 
that  of  exophthalmic  goiter.  However,  the  symptoms  are  less  complex, 
less  definitely  associated,  and  except  for  a  damaged  heart,  less  intense. 
There  is  much  evidence  to  suggest  that  during  the  14.5  years  previous 


_  Fig.  277. — Photomicrograph  oi  section  of  thyroid  X  120  diam.  Type  C.  Regressing 
primary  parenchymatous  hypertrophy  and  hyperplasia.  From  cases  of  clinical  exoph- 
thalmic goiter,  late  stage. 

to  the  onset  of  definite  symptoms  many  of  the  cases  of  non-hyperplastic 
thyroid  may  be  compared  to  the  alcohoHc  tippler  in  that  if  the  soil 
is  right  they  develop  arteriosclerosis,  and  in  many  cases  we  have  the 
combined  picture  of  thyrotoxicosis  and  arteriosclerosis." 

Pathology. — Wilson^ ^  has  recently  described  the  pathology  of  the 
thyroid  in  cases  of  toxic-non-exophthalmic  goiter  as  follows:  "The 
pathology  of  toxic-non-exophthalmic  goiter  of  Plummer's  clinical  group 
2  {i.e.,  those  resembling  exophthalmic  goiter)  is  one  of  increased  paren- 
chyma through  regenerative  processes  in  atrophic  parenchyma  (Fig.  277) 
or  the  formation  of  new  parenchyma  of  the  foetal  type  (Fig.  278)  with 


502 


REGIONAL   SURGERY 


an  increase  in  each  instance  of  secretory  activity  and  of  absorption. 
The  process  is  a  chronic  one  but  sufficiently  active  to  cause  the  patient 
to  consult  a  surgeon  earlier  than  do  those  cases  in  clinical  group  i." 

''The  nearer  the  cases  of  chnical  group  2  (toxic-non-exophthalmics) 
approach,  in  age  and  symptoms,  true  exophthalmic  goiter,  the  shorter 
the  duration  of  the  period  of  goiter  before  operation  and  the  smaller 
the  average  weight  of  the  gland  at  the  time  of  its  removal." 

"The  cases  of  toxic  goiter  of  cHnical  group  i  {i.e.,  those  in  which  the 
symptoms  are  of  the  cardiovascular  variety)  much  more  closely  resem- 
ble cases  of  simple  goiter  in  their  pathology  in  all  respects  than  do  the 


Fig.  278. — Photomicrograph  of  section  of  thyroid  X  120  diam.  Type  D.  Secondary 
regeneration  of  atrophic  parenchyma.  From  casej  of  cUnical  toxic-non-exophthalmic 
goiter. 


cases  of  cUnical  group  2.  A  larger  number  of  them  are  of  the  colloid 
goiter  type,  the  enlargement  of  the  thyroid  has  existed  for  a  longer 
period  before  operation  and  the  portion  of  the  gland  removed  is  mate- 
rially larger  than  in  those  cases  of  clinical  group  2." 

"Finally,  it  may  be  stated  that  all  the  above  pathologic  evidence 
points  to  a  constant  relative  association  of  increased  secretion  and 
increased  absorption  from  the  thyroid  proportional  to  the  degree 
of  toxicity  on  the  part  of  the  patient.  We  have  as  yet  no  absolute 
proof  that  such  secretion  and  absorption  is  the  cause  of,  rather  than 
coordinate  with,  the  symptoms,  but  the  presented  evidence  strongly 
points  to  that  conclusion." 


THE    THYROID 


503 


Treatment. — The  treatment  of  toxic-non-exophthalmic  goiter  is, 
in  the  mild  or  early  stages,  practically  the  same  as  that  of  simple 
goiter.  In  its  severe  or  advanced  stages,  the  mortality  is  as  high  or 
even  higher  than  that  of  exophthalmic  goiter  of  similar  severity  and 
stage  of  symptoms. 

NON-TOXIC  GOITER 


Until  Plummer's^^  differentiation,  the  term  ''simple  goiter"  (Fig. 
281)  included  a  large  percentage  of  cases  without  toxic  symptoms,  and  a 


Fig.  279. 

smaU  percentage  with  toxic  (but  non-exophthalmic)  symptoms.  There 
is  no  doubt  that  the  term  "simple  goiter"  should  be  dropped  and  the 
term  "non- toxic"  substituted  as  covering  the  majority  of  the  cases, 
while  those  cases  which  present  any  toxic  symptoms  should  be  described 
as  "toxic-non-exophthalmic." 

To  a  variable  degree  thyroid  enlargement  may  be  due  to  demands 
made  upon  its  secretion  by  certain  systemic  conditions,  such  as  sexual 
development  at  puberty,  the  goiter  of  adolescence,  the  enlargement 
or  hyperaemia  at  menstruation,  also  that  during  the  latter  part  of 


504 


REGIONAL    SURGERY 


pregnancy,  the  changes  at  the  menopause,  and  last  but  not  least  the 
possible  iodine  demand  occasioned  by  bacterial  infection  of  various 
organs,  especially  severe  tonsillitis. 

The  simple  enlargement  of  the  thyroid  in  girls  at  puberty,  is  a  fairly 
normal  condition  and  indicates  that  menstruation  is  becoming  estab- 
lished. It  very  rarely  occurs  that  colloid  or  diffuse  adenomatous  goiter 
in  the  young  becomes  so  resistant  to  treatment  or  so  annoying  in  pres- 


FlG.   280. 


sure  symptoms  that  extirpation  or  resection  of  a  portion  of  a  gland  is 
necessary,  although  at  times  it  may  be  advisable.  Occasionally  during 
this  period,  however,  an  encapsulated  adenoma  may  develop  into  a 
rounded  tumor  occupying  some  part  of  the  gland.  It  is  best  to  remove 
such  tumors. 

While  a  large  number  of  non-toxic  goiters  begin  at  puberty,  especially 
in  the  female,  many  others  take  their  origin  after  this  period,  the 
average  age  of  onset  of  thyroid  enlargement  in  patients  coming  to  the 


THE   THYROID 


505 


Mayo  Clinic  being  22  years.  These  cases  have  in  many  instances 
an  endemic  origin.  Accumulated  evidence  shows  that  endemic  goiter 
is  frequently  due  to  a  water-borne  irritant.  In  such  cases,  chronic 
intestinal  toxaemia  may  occasion  the  extra  demand  upon  the  gland. 
For  a  thorough  recent  discussion  of  this  most  interesting  phase  of  the 
subject,  the  reader  is  referred  to  McGarrison's^^  excellent  work  on  the 
Etiology  of  Endemic  Goiter.  In  America,  sporadic  cases  are  apparently 
more  numerous  than  those  in  which  an  endemic  relationship^can  be 
traced. 


Fig.  281. 

Figs.    279,    280,    281. — Clinical   diagnosis:  atoxic    (simple)    goiter,    Pathologic   diagnosis: 

diffuse  colloid  goiter  with  atrophied  parenchyma.     Group  H. 

The  symptoms  are  wholly  those  of  pressure  on  the  adjacent  parts, 
except  in  those  cases  in  which  atrophy  of  the  parenchyma  has  progressed 
so  far  that  secondary  symptoms  of  myxoedema  have  supervened. 

Pathology. — Wilson'*''  has  shown  in  a  report  on  2356  thyroids  from 
patients  with  non-toxic  goiter  operated  on  in  the  Mayo  Clinic,  that 
only  a  small  fraction  of  i  per  cent,  showed  any  degree  of  hypertrophy 
and  hyperplasia  of  the  parenchyma,  9  per  cent,  showed  secondary 
regeneration  of  atrophic  parenchyma,  23  per  cent,  were  foetal  adenomas 
and  67  per  cent,  were  adult  adenomas,  colloid  goiters  or  diffuse  adeno- 


5o6  REGIONAL   SURGERY 

matoses  (Figs.  2  79  and  280) .  The  most  striking  point  about  the  pathol- 
ogy in  these  non- toxic  cases  is  the  relatively  small  number  of  them  which 
show  even  a  fair  amount  of  apparently  active  parenchyma.  The  bulk 
of  the  gland  in  almost  every  instance  consists  of  dense  colloid  secretion 
or  of  degenerated  fibrous  or  hyalin  material. 

Operations.- — The  operative  procedure  for  the  uncomplicated  non- 
toxic thyroid  is  approximately  the  same  as  that  for  the  simpler  types  of 
exophthalmic  goiter;  section  of  the  muscles,  however,  is  not  often  re- 
quired. Operations  on  adenomas,  colloid  thyroids  or  diffuse  adenoma- 
toses as  a  rule  involve  but  slight  risk  to  the  life  of  the  individual. 
Many  patients  who  are  so  afflicted  wish  to  be  relieved  of  the  deformity, 
tracheal  pressure,  hoarseness  or  possibly  of  a  severe  neuralgia.  Despite 
the  enormous  discomfort  and  suffering  with  which  the  disease  may  be 
accompanied,  actual  death  therefrom  occurs  but  rarely  and  then  only 
from  intrathoracic  or  from  malignant  or  degenerative  change  in  the 
gland.  The  occasional  large  goiter  observed  in  the  cretin  has  little  or 
no  active  parenchyma.  If  these  goiters  cause  distress,  they  should  be 
removed.  Changes  in  the  voice  are  often  caused  by  the  presence  of  a 
non-toxic  goiter.  Matthews,^^  in  the  examination  of  1000  cases,  has 
shown  that  large,  right-sided  goiters  quite  frequently  produce  paresis 
of  the  left,  recurrent,  laryngeal  nerve.  It  is,  therefore,  advisable  to 
make  a  laryngoscopic  examination  before  doing  a  thyroidectomy  which 
otherwise  may  be  blamed  for  the  paresis  discovered  later.  Loss  of 
voice  through  injury  of  the  recurrent  laryngeal  nerve  during  operation 
is  not  a  rare  occurrence.  Possibly  10  per  cent,  of  patients  have  some 
temporary  hoarseness  and  about  5  per  cent,  a  permanent  dif&culty  with 
one  cord,  but  rarely  with  loss  of  voice.  These  usually  occur  among 
those  who  already  had  some  paresis  or  paralysis  due  to  the  pressure  of 
a  goiter.  The  left  recurrent  nerve,  which  is  more  frequently  affected, 
lies  slightly  deeper  than  the  right  and  has  received  more  stretching  dur- 
ing embryonic  life.  This  may  account  in  some  measure  for  its  greater 
susceptibility  to  injury  from  pressure.  Extensive  exposure  of  the 
nerve,  as  is  done  in  some  clinics,  is  necessary  only  in  an  operator's  early 
experience,  or  in  operating  upon  complicated  nodular  thyroids  which 
extend  beneath  the  trachea  and  which  may  have  displaced  the  nerve. 
The  scar  tissue  resulting  from  the  traumatism  of  a  too  free  exposure 
of  a  nerve  may  itself  lead  to  secondary  paresis. 

In  a  series  of  100  consecutive  cases  in  other  than  goiter  patients,  or 
patients  coming  for  examination  on  account  of  laryngeal  symptoms, 
there  were  found  one  case  of  total  paralysis  of  the  left  cord  without 


THE    THYROID  507 

noticeable  symptoms,  one  case  of  partial  and  one  of  complete  abductor 
paralysis,  and  two  of  partial  loss  of  both  motions  of  the  left  cord.  In 
one  case  only,  the  right  cord  showed  a  deficiency  of  both  motions. 
These  patients  were  more  than  normally  liable  to  affections  of  the  cords, 
since  most  of  them  came  for  other  pathologic  conditions  in  the  nose  and 
throat.  But,  since  goiter  patients  are  also  especially  affected  by  dis- 
eases of  the  nose  and  throat,  it  might  be  considered  proper  to  deduct 
from  the  percentage  due  to  goiter  the  6  per  cent,  found  in  these  cases. 
This  would,  in  cases  of  slight  enlargement  of  the  thyroid,  make  the  per- 
centage for  the  right  and  left  cord  nearly  equal,  while  in  cases  of  greater 
enlargement  the  left  cord  would  still  show  a  relatively  greater  tendency 
to  paralysis  from  pressure,  probably  on  account  of  the  great  stretching 
this  nerve  receives  in  its  embryonic  development. 

Intrathoracic  goiters  and  deep  substernal  goiters  are  of  serious  im- 
port and  are  found  about  once  in  40  operations  for  simple  goiter.  SUght 
substernal  projections  are  much  more  frequent.  The  diagnosis  rests 
on  (i)  dull  area  on  percussion,  (2)  the  Rontgenogram,  and  (3)  evidences 
of  substernal  pressure  (dilated  veins,  obstructive  dyspnea  and  palpa- 
tion of  the  upper  pole  of  the  gland  just  above  the  clavicle).  Probably 
one-sixth  of  the  original  gland-cells  are  competent  to  furnish  all  secre- 
tion necessary.  It  is  best  to  preserve  this  much  or  more  of  the  gland 
until  there  is  more  evidence  furnished  that  all  of  the  gland  can  be  re- 
moved with  no  ill  effect  as  is  claimed  by  some  surgeons  in  their  treat- 
ment of  exophthalmic  goiter. 

As  regards  the  non-surgical  treatment  of  goiter,  there  is  no  question 
but  that  many  cases  of  simple  goiter,  especially  of  the  adolescent  type, 
undergo  a  natural  resolution,  which  is  also  true  of  those  congestions  and 
enlargements  occasionally  observed  during  pregnancy.  In  the  hyper- 
aemic  goiters  of  adolescence  some  form  of  iodine  treatment  may  have  a 
favorable  effect.  In  encapsulated  adenomas  the  use  of  iodine  may 
manifest  a  temporary  favorable  effect  on  the  surrounding  gland,  but 
its  effect  on  the  encapsulated  tissue  is  uncertain.  Its  use  on  goiters  of 
long-standing  in  patients  between  the  ages  of  35  and  60  seems  to  stimu- 
late the  activity  of  the  thyroid  and  to  cause  degenerative  changes. 
Considering  specific  intestinal  toxemia  as  a  causative  factor,  the  more 
recent  experience  of  McGarrison^^  in  the  non-surgical  treatment  seems 
to  indicate  the  use  of  thymol,  salol  and  iodin  as  intestinal  antiseptics. 
The  administration  of  thyroid  has  rather  an  uncertain  effect,  yet  ap- 
parently produces  favorable  results  in  the  early  treatment  of  simple 
goiters. 


5o8 


REGIONAL   SURGERY 


In  operating  on  the  thyroid,  the  gland  is  best  exposed  through  a 
transverse  incision  made  low  down  in  the  neck,  the  skin  and  platysma 
being  reflected  upward  and  downward  from  the  incision.  If  further 
exposure  is  required  the  sternohyoid  may  be  divided  high  up  in  the  ex- 
posed area.  High  division  of  the  muscle  preserves  the  nerve  supply 
intact  and  later  prevents  adhesion  between  the  line  of  union  of  the 
sutured  muscle  and  that  of  the  skin.  Adhesion  between  the  scar  in 
the  muscle  and  that  in  the  skin  makes  the  latter  move  with  the  muscle 
in  an  uncomely  fashion.  If  one  lobe  of  the  gland  is  much  more  enlarged 
than  its  fellow  that  large  lobe  should  be  extirpated.     If  both  lobes  are 


1 

^ 

flfc  Vf  1 

'..'^^^HH 

-IMP""            >^ 

Fig.  282. — Enucleation  of  cystic  goiter.     Capsule  opened. 

symmetrically  enlarged,  division  of  the  isthmus  and  resection  of  por- 
tions of  both  lobes  are  indicated  and  give  the  best  cosmetic  results. 
Adenomas  encapsulated  in  the  middle  line  should  be  enucleated  and 
the  isthmus  divided  (Fig.  282).  Adenomas  encapsulated  in  the  lateral 
lobes  may  be  enucleated  or  the  whole  affected  lobe  may  be  extirpated. 

The  mortality  from  operations  on  goiters  (other  than  malignant) 
is  very  low,  no  matter  whether  the  disease  is  the  so-called  simple  goiter 
(in  which  class  there  may  be  occasional  complications)  or  exophthalmic 
with  hyperplasia  of  the  gland. 

The  results  of  operations  on  simple  goiters  are  well  known  to  be 


THE    THYROID  509 

exceedingly  satisfactory.  Severe  myxoedema  is  but  a  rare  complica- 
tion following  such  operations,  especially  if  the  area  of  the  gland  nearest 
the  capsule  be  preserved.  The  large  colloid  masses  in  the  interior  of 
these  glands  represent  the  bulk  of  the  tumor  but  the  least  amount  of  the 
working  area  of  thyroid  tissue. 

MALIGNANT  TUMORS 

Malignant  tumors  of  the  thyroid  are  not  numerous.  Less  than  i 
per  cent,  of  the  cases  operated  on  in  our  Clinic  show  malignancy.  This 
of  course  does  not  include  those  patients  who  come  for  examination 
and  are  considered  inoperable.  Both  carcinoma  and  sarcoma  occur, 
the  former  with  much  the  more  frequency.  Carcinomas  are  usually 
of  the  alveolar  type,  and  sarcomas  of  the  spindle-celled  t\pe.  Clin- 
ically, it  is  often  impossible  to  differentiate  the  two.  When  a  rapidly 
growing,  non-inflammatory  hard  tumor  appears  in  a  patient  of  the 
cancer-bearing  age  its  malignancy  is  strongly  suggested.  The  diagno- 
sis should,  if  possible,  be  made  before  the  growth  has  penetrated  its 
capsule  and  involved  the  neighboring  structures,  e.g.,  the  trachea  and 
muscles. 

Treatment. — The  only  treatment  which  affords  any  hope  of  relief 
is'^free  removal  of  the  whole  of  the  thyroid  tissue.  Unfortunately, 
early  glandular  and  lung  metastases  are  common.  In  most  cases,  the 
growth  has  proceeded  beyond  its  capsule  before  the  patient  comes  to 
the  surgeon  and  the  ultimate  results  are  not  promising.  When  the 
tumor  recurs,  its  progress  is  more  rapid  than  before  operation. 

REFERENCES 

^  Parry:  "Collections  from  the  Unpublished  Medical  Writings  of  the  Late 
Caleb  Hillier  Parry,"  London,  1825.  "Elements  of  Pathology  and 
Therapeutics,"  181 5. 

2  MoRGAGNi:  "De  scdibus  et  causis  morborum,"  Cap.  XXI,  Art.  36;  Cap. 
XVII,  Art.  19;  Cap.  XXIII,  Art.  4  and  6. 

^  Flajan:  "Collezione  d'osservazioni  e  riflessioni  di  chirurgia,  p.  270. 

*  Graves:  Lond.  Med.  &  Surg.  Jour.,  May  23,  1835.     (Repr.  "System  of 

Clinical  Medicine,"  Dublin,  1843.) 

*  Basedow  :Wochnschr.  f.  d.  ges.  Heilk.,  1840,  pp.  13-14. 

*  Charcot:  Compt.  rend.  Soc  de  biol.,  1856,  Paris,  1857,  2  s.,  HI,  pt.2,  pp. 

43-56;  also,   Gaz.  med.  de  Paris,  1856,  3  s.,  583,  599. 
W.  Graefe:  Arch.  f.  Ophth.,  1857,  III,  278. 
^Stellwag:  Med.  Jahrb.,  Wien,  1869,  XVII,  25-54. 

*  Marie:  "Contribution  a  I'etude  et  au  diagnostic  des  formes  frustes  de  la 

maladie  de  Basedow,"  Paris,  1883. 


5IO  REGIONAL   SURGERY 

"  Gunn:  Brit.  Med.  Jour.,  London,  April  i8,  1885. 

^^  Kocher:  Deutsche  Ztschr.  f.  Chir.,  Leipzig,  1874,  IV,  417-440. 

^2  McEBius:  Schmidt's  Jahrb.,  1886,  No.  210,  p.  237. 

^^  Tschuewsky:  Pfliiger's  Arch.  f.  Physiol.,  Bonn,  1903,  XCVII,  210-308. 

^*  Gaskell:  "The  Origin  of  Vertebrates,"  London,  1908,  216-217. 

^^  Marine:  Jour.  Exper.  Med.,  1913,  XVII,  379-395. 

^^  Baumann:  Miinchen.  Med.  Wchnschr.,  1896,  XLIII,  pp.  309,  398,  476,  11 53. 

^^  Eppinger,   Falta  and   Rudinger:  VerhandL   d.   Kong.   f.   innere   Med., 

Wiesbaden,  1908,  XXV,  352-359. 
^*  Oswald:  Ztschr.   f.   physiol.   Chem.,    1899,   XXVII,    14-49;    Ibid.,    1901, 

XXXII  1 21-144. 
^'  Marine:  Jour.  Am.  Med.  Assn.,  1912,  LIX,  325-327. 
2°  Hunt:  Jour.  Am.  Med.  Assn.,  1907,  XLIX,  1323-1329. 
^^  Smith  and  Broders:  Jour.  Am.  Med.  Assn.,  1914,  LXII,  113-117. 

22  Kendall:  Jour.   Am.   Med.   Assn.,   1915,  LXIV,    2042-2043;   Jour.   Biol. 

Chem.,  1915,  XX,  501-509. 

23  Wilson:  Northwest  Medicine,  Seattle,  1913,  V,  1-5. 

2*  MacCarty:  Surg.,  Gynec.  &  Obst.,  Chicago,  1913,  XVI,  406-411. 

2^  Plummer:  Amer.  Jour.  Med.  Sc,  1913,  CXLVI,  790-795. 

2s  Kocher:  "Ueber   Krankheitsercheinungen  bei   Schilddriisenerkrankungen 

geringen  Grades."     Dissertation:  Nobel- Conferenz  gehalten  am  II  Dez., 

1909,    vor   der    Kgl.    Schwedischen   Akademia   der   Wissenschaften    zu 

Stockholm. 
2^  Dalrymple:  Jour.  Morbid  Anatomy,  1828,  I,  43-47. 
28  Mcebius:  Centralbl.  f.  Nervenh.,  Leipzig,  1886,  IX,  356-358 
^'Landstrom:  Nord.  med.  Ark.,  Stockholm,  1908,   i,  afd.,  3-4  Hft.,  No.  8, 

19-196. 
3"  Wilson:  Am.  Jour.  Med.  Sc,  1913,  CXLVI,  781-790. 
3^  Mcebius:  Miinchen.  med.  Wchnschr.,  1903,  I,  149. 

32  Rogers  and  Beebe:  Arch.  Int.  Med.,  1908,  II,  297-329. 

33  Porter:  Jour.  Am.  Med.  Assn.,  1913,  LXI,  88-93. 

3^W6lfler:  Cited  by  Kocher,  "Textbook  of  Operative  Surgery,"  London, 

1903,  p.  149. 
35  Crile:  Surg.,  Gynec.  &  Obst.,  1911,  XIII,  170-173. 
3^Jaboulay:  Lyon  med.,  1897,  LXXXVI,  251-256. 
"Jonnesco:   Ann.   d'ocul.,   Paris,    1897,  CXVII,  161-175;  also  (transl.)    J. 

Ophth.,  Otol.  &Laryngol.,  N.  Y.,  1897,  IX,  224-238. 

38  Wilson:  Am.  Jour.  Med.  Sc,  1914,  CXLVII,  344-351. 

39  McGarrison:  The  Milroy  Lectures  on  the  Etiology  of  Endemic  Goiter." 

Lancet,  London,  1913,  I,  147,  219,  365. 
^°  Wilson:  Jour.  Am.  Med.  Assn.,  1914,  LXII,  111-112. 
^^  Matthews:  Jour.  Am.  Med.  Assn.,  1910,  LV,  826-827. 


SECTION  XX 
THE  PARATHYROIDS 

By 

CHARLES  H.  MAYO    A.  M.,   M.  D.,  LL.  D.,   F.  A.   C    S., 

Rochester,  Minn. 

The  diminutive  size  of  the  parathyroids  and  the  intimate  topo- 
graphic relationship  between  them  and  the  thyroid  make  it  intelligible 
why,  for  a  long  time,  investigators  failed  to  consider  a  functional  inde- 
pendence of  these  little  bodies.  In  1880  a  Swedish  anatomist,  Sandstrom, 
first  described  the  parathyroids  in  man,  also  in  various  other  species 
of  animals.  In  the  beginning,  Sandstrom  viewed  these  structures  as 
arrested  embryonic  stages  in  the  development  of  the  thyroid.  In  1891 
Gley  for  the  first  time  discussed  the  physiologic  importance  of  the  para- 
thyroidal  tissue.  This  investigator  believed  that  after  total  thyroidec- 
tomy these  glandules  assumed  the  function  of  the  thyroid.  Many  other 
investigators  (Kocher,  Reverdin,  v.  Eiselsberg,  ct  al.)  made  the  observa- 
tion that,  following  total  extirpation  of  the  thyroid  in  various  animals, 
in  some  cases  the  resultant  condition  was  cachexia  strumipriva,  in 
others  typical  tetany.  These  dissimilar  effects  are  explained  in  the 
light  of  anatomy,  which  shows  the  differences  in  the  topography  of  the 
parathyroids  in  individual  species  of  animal.  Through  the  investiga- 
tions of  Pineles,  Biedl,  Erdheimjd  a/., the  independence  of  these  little 
bodies  has  been  established  beyond  doubt.  Many  maintain  that  the 
evidence  today  is  sufficiently  extensive  and  conclusive  to  prove  that 
tetany  following  operation  on  the  thyroid  is  not  a  tetania  strumipriva, 
but  a  tetania  parathyreo-priva.  Divergent  views  still  exist,  however, 
with  regard  to  the  underlying  pathology  of  the  various  other  forms  of 
tetany,  but  the  observations  of  Jeandelize,  Pineles,  Escherich,  Erdheim, 
Chvostek,  Rudinger,  Haberfeld,  Geluke,  MacCallum,  el  al.,  strongly 
support  the  theory  that  all  of  these  rest  on  a  pathogenetically  uniform 
basis,  and  that  all  are  founded  on  an  absolute  or  relative  insufficiency  of 
the  parathyroids. 

An  etiologic  role  in  several  other  diseases  has  been  attributed  to  the 
parathyroids  by  some  writers.  Berkeley  assumed  a  hypoparathyroidal 
genesis  for  paralysis  agitans,  basing  his  view  on  the  ground  of  the  favor- 
able therapeutic  effect  of  treatment  with  preparations  of  parathyroidal 

5" 


512  REGIONAL   SURGERY 

tissue.  This  author  reports  60  cases,  almost  65  per  cent,  of  which 
manifested  a  decided  improvement  from  the  administration  of  Beebe's 
parathyreo-nucleo-proteid.  In  four  cases  of  paralysis  agitans,  Roussy 
and  Clunet  found  the  parathyroids  enlarged  and  presenting,  on  histologic 
examination,  simple  hyperplasia  with  much  colloid  and  a  great  number 
of  oxyphilic  cells.  These  authors  viewed  this  finding  as  indicative  of 
parathyroidal  hyperfunction.  Roussy  and  Clunet  demonstrated  a 
directly  unfavorable  influence  on  the  disease  of  paralysis  agitans  from 
the  employment  of  parathyroidal  medication.  In  three  cases  of  this 
same  disease  Erdheim  found  the  parathyroids  normal.  Lundborg  'and 
Chvostek  have  ascribed  myasthenia  pseudo-paralytica  to  excessive 
function  of  the  parathyroidal  tissue.  Chvostek  views  myasthenia  and 
tetany  as  diseases  which,  in  manifestations,  are  diametrically  apposed. 
This  is  indicated  in  the  electrical  and  other  reactions.  Evidences  on 
the  part  of  the  muscular  fibers  rather  point  to  myasthenia  as  belonging 
to  the  diseases  of  the  muscular  system.  Haberfeld  states  that  many 
cases  are  known,  among  which  were  hypertrophy  and  genuine  tumors 
of  the  parathyroids,  without  the  slightest  manifestations  of  myasthenia. 

Embryology. — The  parathyroids  arise  from  the  dorsal  part  of  the 
third  and  fourth  branchial  clefts.  There  are  usually  two  on  each  side, 
but  variations  from  this  are  not  infrequent.  The  thymus  arises  from 
the  ventral  part  of  the  third  cleft.  From  this  close  association  of  the 
parathyroid  and  the  thymus  in  the  third  cleft  the  parathyroid  may 
remain  applied  to  or  even  enclosed  within  the  thymus.  The  para- 
thyroid derived  from  the  fourth  pouch  becomes  later  in  develop- 
ment annexed  to  the  thyroid,  and  can  eventually  be  embraced  by  thy- 
roidal tissue.  Embryologic  investigations  up  to  the  present  support 
the  view  that  the  relation  of  the  parathyroids  to  the  thyroid  is  purely 
topographic  (Falta). 

Anatomy. — Various  tissues  in  the  vicinity  of  the  thyroid  may  grossly 
simulate  a  parathyroid,  namely,  lymph  nodes,  hemolymph  nodes,  fat,  ac- 
cessory or  aberrant  thyroids  and  thymic  rests  (Figs.  283,  284  and  285). 
It  has  been  stated  that  for  differentiation  and  exclusion  of  these  tissues, 
microscopic  examination  is  absolutely  essential.  That  this  statement 
is  true  viewed  in  the  light  of  limited  experience  in  operations  on  the 
thyroid  is  not  to  be  denied,  but  it  is  equally  true  that  with  sufficiently 
extensive  anatomical  experience  of  this  region  on  the  living,  the 
parathyroids  can  usually  be  detected.  Because  of  post-mortem  changes, 
the  differentiation  is  not  so  readily  made  grossly  on  the  cadaver,  but 
in  this  case  also  with  increasing  experience,  the  percentage  of  positive 


THE    PARATHYROIDS 


513 


diagnoses  of  the  parathyroids  is  greatly  raised.  This  has  been  proved 
by  a  comparison  of  results  in  the  early  with  those  in  the  late  cases  of 
an  extensive  anatomic  series.  In  the  former  only  36  per  cent,  of 
suspected  structures  wasparathyroidal;  in  the  latter,  about  90  per  cent. 
The  number  of  parathyroids  is  usually  stated  as  four,  occurring  in 
pairs — a  superior  and  an  inferior  on  each  side.     While,  however,  the 


Fig.  283. — Posterior  view  of  thyroid.     P.,  Parathyroids;  L.N.,  lymph  nodes. 
Journ.  A.  M.  A,.  June,  191 2.) 


{Ginsburg 


studies  of  some  have  shown  that  the  numerical  constancy  of  these 
glandules  is  subject  to  slight  variations,  the  investigations  of  others 
indicate  that  this  number  is  often  diminished  by  one  or  more,-  and  oc- 
casionally increased.  In  125  autopsies  on  the  human,  Berkeley  found 
about  an  average  of  two  and  one-half  parathyroids  per  person.  In 
138  autopsies  by  Verebety  four  parathyroids  were  found  108  times. 

The  location  is  not  constant.  Halstead  and  Evans  found  the  higher 
of  the  two  glandules  of  one  side  to  be,  on  the  average,  about  at  the  level 
of  the  upper  and  the  middle  thirds  of  the  lateral  lobes  of  the  thyroid. 
The  lower  of  the  two  parathyroids  is  usually  not  far  from  the  lower 
pole,  rarely  as  high  as  the  middle  of  the  thyroid  lobe.  Very  regularly 
the  little  bodies  are  situated  on  or  very  near  the  posterior  border  of  the 


514 


REGIONAL    SURGERY 


lateral  lobe  of  the  thyroid,  and  more  or  less  in  line  with  the  "channel" 
of  anastomosis — an  important  landmark — between  the  superior  and 
the  inferior  thyroid  arteries.  Among  the  variations  in  location  are, 
at  or  above  the  tip  of  the  superior  pole  of  the  thyroid;  on  its  outer  sur- 
face; at  or  below  the  inferior  pole,  even  within  the  bony  thorax;  on  the 
anterior  surface  of  the  isthmus;  and  within  the  thyroid.  Rogers  and 
Ferguson  cite  a  case  in  which  a  parathyroid  was  found  in  the  middle  of 
the  posterior  surface  of  the  pharynx  at  the  level  of  the  lower  border  of 


Fig.  284. — Ventral  aspect  of  the  thyroid  gland.  Note  the  large  number  of  lymph- 
nodes,  some  having  a  separate  arterial  twig.  There  are  no  parathyroids  in]this  drawing. 
{Ginsburg,  Journ.  A.  M.  A.) 

the  cricoid  cartilage.  The  writer  has  found  an  accumulation  of  para- 
thyroidal  tissue  in  a  cavity  of  the  hyoid  bone.*  A  fistulous  communica- 
tion was  present.  Accessory  and  aberrant  parathyroids  are  not  infre- 
quent. Small  accumulations  of  parathyroidal  cells  are  found  variously 
located  and  explain  many  of  the  conflicting  views  as  to  the  number  and 
location  of  these  structures,  also  the  divergence  in  experimental  results. 
In  the  light  of  recent  research,  it  is  clearly  conceivable  that  in  the  form 
of  this  scattered  parathyroidal  tissue,  after  an  assumed  complete  para- 


THE   PARATHYROIDS 


515 


thyroidectomy,  sufficient  functionating  glandular  substance  may  re- 
main to  defeat  the  object  of  the  experiment.  Such  cellular  accumula- 
tions have  been  described  by  Miiller  and  Erdheim.  Getzowa  has 
found  these  metameric  epithelial  bodies  frequently  within  the  thyroid, 
and  practically  always  intrathyroidal  in  the  absence  of  the  superior 
parathyroids.     Similar  sparse,  isolated  groups  of  parathyroidal  cells 


-^■'  '~ 

^Jt^^aisr''W-^  '-r- 

'^. 

il^m'^ 

(<' 

%nii^\^VW 

0 

'pLX^f " 

'•\ 

^m!Wm\ 

jg^.wsftk  n     ^  ^^  ■  ^' 

^-^ 

Fig.  285. — Ventral  aspect  thyioid  gland.     Note  the  lymph  nodes  in  pretracheal   region  in 
dose  association  with  the  thyroid  gland.     {Ginsbiirs,  Jouni.  A.  M.  A.) 


are  also  found  in  the  presence  of  a  superior  thyroid,  and  these  Getzowa 
designates  as  a  third  epithelial  body  of  a  rudimentary  fifth  branchial 
cleft.  The  intrathyroidal  location  of  parathyroidal  tissue  is  quite  com- 
mon in  several  quadrupeds,  notably  in  the  horse,  dog  and  goat.  The 
presence  of  nodules  of  thyroid,  thymus  and  lymphatic  nodes  near  the 
usual  site  of  the  parathyroids  is  frequently  noted.     In  263  specimens 


5i6 


REGIONAL   SURGERY 


selected  as  resembling  parathyroids,  in  proved  to  be  thyroid  tissue  in 
large  part  (Rogers  and  Ferguson).  The  same  investigators  found 
thymic  remnants  present  in  a  considerable  number,  and  these  occurred 


Parathyroid  glandules.     {Hal sled- Evans.) 


in  the  aged  as  well  as  in  the  young,  but  mostly  in  infants.  Ginsburg 
emphasizes  the  difficulty  in  differentiating  parathyroids  from  closely 
allied  lymphatic  nodes.  These  nodes  are  numerous  in  the  region  of  the 
thyroid,  and  at  times  their  size,  relation  and  blood-supply  so  simulate 
those  of  the  parathyroid  that  they  can  be  ^differentiated  only  by  his- 
tologic examination. 


THE    PARATHYROIDS 


517 


The  parathyroids  are  described  as  flattened,  ovoid  or  reniform 
bodies,  each  covered  by  a  thin  fibrous  capsule,  beneath  which  a  fine 
anastomosis  can  be  seen.  The  surface  presents  an  exceedingly  fine, 
barely  visible,  granular  appearance,  probably  due  to  the  blood-vessels 
(Halstead  and  Evans).  The  color  is  reddish,  reddish  yellow,  or  brown- 
ish red.  The  length  varies  from  3  to  15  mm.;  the  width  or  thickness 
is  about  2  mm.  In  Halstead  and  Evans'  excellent  description  of  the 
vascular  supply  it  is  stated  that,  "each  glandule  has  invariably  its 
special  artery  which  might  be  designated  the  superior  and  the  inferior 
parathyroid  artery — right  and  left  (Fig.  286).  The  vessel  is  large  in 
proportion  to  the  organ  supplied,  and  this  aids  in  the  body's  identifi- 


FiG.  2S7. — Principal  culL.     'J'l'oLj 

cation.  The  glandules  are  quite  free,  and,  as  cherries  on  the  stem, 
hang  from  the  artery,  which  enters  the  hilus."  Both  parathyroidal 
arteries  usually  arise  from  the  inferior  thyroid,  but  frequently  they  take 
origin  from  the  anastomosing  channel  between  the  inferior  and  superior 
thyroid  vessels.  Beside  these  usual  sources,  other  types  of  origin  are 
described.  To  be  noted,  however,  is  the  simulating  vascular  plan  of 
the  neighboring  lymphatic  glands. 

Histology. — The  glandule  is  composed  of  a  mass  of  cells  enclosed  by 
a  thin  fibrous  capsule.  Irregular  processes  project  inward  from  the 
capsule.     The  main  types  of  cells  are  the  so-termed  i:)rincipal  cells, 


5i8 


REGIONAL   SURGERY 


Fig.  288. — Masses  of  oxyphile  cells.     {Pool. 


Fig.  289. — Diffuse  hypertrophy  of  the  parathyroid.  To  the  right  and  below  accumula- 
tions of  oxyphilic  cells;  above,  alveoli  with  small  oxyphilic  cells.  To  the  left  and  below 
columns  of  principal  cells. 


THE    PARATHYROIDS  519 

eosinophiles  and  fat  cells.  The  amount  of  fat  is  very  variable,  and  is 
present  both  as  a  cellular  metamorphosis  and  as  an  infiltration  of  the 
stroma.  In  later  life  fat  may  considerably  predominate  in  the  struc- 
ture of  the  parathyroid.  Welsh  has  classified  the  parathyroidal  cells 
into  two  principal  types:  (i)  the  "principal  cells,"  which  greatly  pre- 
dominate (Fig.  287) ;  (2)  the  "oxyphiHc  cells"  (Figs.  288  and  289).  The 
former  apparently  consist  of  only  a  nucleus  and  a  membrane,  which  is  de- 
cidedly eosinophilic,  the  cellular  body,  as  a  rule,  not  being  pronounced. 
The  nucleus  is  large  and  the  chromatin  network  open.  The  oxyphilic 
cells  have  a  relatively  large  body  with  fine,  strongly  eosinophilic 
granules.  The  nucleus  is  small,  deeply  staining,  and  with  chromatin 
closely  arranged.  These  cells  are  variously  distributed.  They  are 
frequently  noted  as  compact  accumulations  beneath  the  capsule,  as 
anastomosing  columns  and  singly  or  in  small  groups  scattered  among 
the  principal  cells.  Many  other  cellular  forms,  intervening  between  the 
two  main  types,  have  been  observed.  These  cells  are  not  considered 
characteristic. 

Physiology. — Viewed  in  the  light  of  experimental  results,  clinical 
and  surgical  experiences  the  parathyroidal  glandules  appear  to  be 
structures  of  vital  importance.  However,  the  exact  nature  of  the 
function  of  the  parathyroidal  tissue  remains  still  in  the  dark.  The 
summation  of  evidence  reported  by  able  investigators  in  physiological 
research  indicates  that  in  the  assumed  complex  correlationship  among 
the  organs  of  internal  secretion  these  glandules  play  an  important  role 
in  the  maintenance  of  physiological  equilibrium. 

Various  combinations  of  investigations  on  animals  of  different  species 
have  uniformly  estabhshed  that  from  the  removal  of  all  four  parathy- 
roids— provided  that  no  accessory  parathyroidal  structure  is  present — 
fatal  tetany  results.  If  two  or  three  of  the  glandules  be  removed,  the 
animal,  as  a  rule,  lives,  but  undergoes  a  transitory  tetany.  In  the 
latter  case,  occasionally  the  tetanic  attacks  recur  under  certain  con- 
ditions, for  example,  pregnancy  and  various  intercurrent  diseases. 
Such  animals  are,  therefore,  in  a  state  of  latent  tetany.  It  is  stated 
that  the  animal  tends  to  withstand  a  loss  of  one-half  its  parathyroidal 
tissue  without  injury.  Following  removal  of  a  part  of  the  parathy- 
roidal substance,  the  remaining  portion  undergoes  hypertrophy,  as 
noted  by  Halstead,  Biedl,  Haberfeld  and  Schilder,  etal.  This  evidence 
of  the  importance  of  the  parathyroids  in  the  production  of  experimental 
tetany  has  been  supplemented  by  observations  on  post-operative  tetany 
in  the  human.     Erdheim  is  credited  as  having  been  the  first  to  accu- 


520  REGIONAL   SURGERY 

rately  demonstrate  this  condition  following  thyroidectomy  in  man. 
However,  despite  these  convincing  experimental  and  post-operative 
observations,  there  are  some  authors  who  do  not  accept  the  parathyreo- 
privous  nature  of  tetany,  being  unwilling  to  admit  such  an  important 
role  for  structures  so  insignificant.  The  apparent  benefit  from 
the  administrations  of  the  thyroid  seem  to  lend  support  to  this 
objection,  but  these  results  have  not  been  sufficiently  definite  for  a 
positive  opinion. 

Still  less  uniformly  an  agreement  exists  as  to  the  parathyreoprivous 
nature  of  the  remaining  forms  of  tetany.  Several  investigators,  notably 
Erdheim,  Yanase,  Haberfeld,  et  al.,  support  the  theory  of  intrapara- 
thyroidal  hemorrhage  in  the  case  of  infantile  tetany.  Such  hemorrhages 
are  assumed  to  occur  during  intrauterine  life  or  at  the  time  of  labor, 
and  to  the  occurrence  of  these  hemorrhages  are  also  attributed  tetanic 
attacks  of  later  childhood  and  even  adult  life.  In  such  cases  an  hypo- 
plastic condition  of  the  parathyroids  has  been  observed,  and  the  only 
indication  of  the  early  bleeding  may  be  the  presence  of  hematogenous 
pigment,  together  with  evidence  of  inhibited  growth  of  functional 
tissue.  The  existing,  limited  parathyroidal  material  suffices  to  main- 
tain a  state  of  equilibrium  in  the  presence  of  normal  conditions,  but 
with  the  advent  of  some  intercurrent  disturbance,  such  as  the  common 
gastrointestinal  diseases  of  the  young,  infections,  pregnancy,  etc.,  the 
glandules  become  relatively  insufficient  for  the  increased  demand.  Be- 
side the  role  of  these  little  bodies,  there  is  some  other  factor  which 
precipitates  the  tetanic  attack.  The  nature  of  this  is  unknown.  The 
picture  presented  in  parathyroidectomized  animals  is  characteristic, 
and  based,  for  the  most  part,  on  a  state  of  hyperexcitability  of  the 
nerves,  not  the  muscles.  There  is  a  latent  period  of  about  40  hours, 
then  from  a  gradual  change  in  the  excitability  of  the  nervous  system, 
the  animal  presents  various  convulsive  manifestations,  which  lead 
to  most  intense  spasms.  The  result  may  be  death,  or  recovery  with 
repetition  of  the  attacks.  There  are  also  sensory,  gastrointestinal  and 
vasomotor  disturbance,  and  an  underlying  cachexia.  Voegtlin  and 
MacCallum  emphasize  the  significance  of  electrical  excitability  of  the 
motor  nerves,  regarding  it  as  a  most  characteristic  criterion  of  the  ex- 
istence of  tetany.  This,  these  investigators  say,  affects  all  the  measure- 
ments, but  the  variation  from  normal  in  the  K.  0.  and  A.  O.  seem  to 
be  far  greater  than  that  of  K.  C.  and  A.  C.  Five  ma.  are  needed  to 
produce  the  slightest  contraction  in  the  normal,  but  in  tetany  }{o 
ma.  when  passed  through  the  nerve  may  suffice  to  cause  a  violent  jerk. 


THE   PARATHYROIDS  52 1 

MacCallum  further  states  that  apparently  this  same  electrical  hyper- 
excitability  is  present  in  the  sensory,  the  vegetative  and  the  sympa- 
thetic nerves,  and  is  the  underlying  cause  of  all  the  symptoms,  although 
itself  is  the  effect  of  the  change  that  follows  the  loss  of  the  glands. 
Experimentation  has  proved  that  this  state  of  the  nerves  is  pro- 
duced by  some  alteration  in  the  circulating  blood.  Some  ascribe 
the  condition  of  the  nervous  system  to  a  specific  poison  which  arises, 
following  the  removal  of  the  parathyroids.  MacCallum  suggests  that 
it  may  be  something  which  withdraws  a  moderating  and  quieting  in- 
fluence from  the  nerve  cells  and  leaves  them  in  an  unbalanced  and 
hyperexcitable  condition.  This  assumed  element  causing  a  change  in 
the  blood  in  tetany  precipitates  or  renders  useless  the  calcium  of  the 
nerve  cells.  After  parathyroidectomy,  a  solution  of  calcium  salts  in- 
travenously injected  or  administered  in  large  doses  by  mouth  stops 
very  promptly  the  tetanic  symptoms,  but  the  symptoms  re-appear 
when  the  effect  of  the  calcium  is  gone.  Like  strontium  and  magnesium, 
it  is  effective  in  tiding  over  the  danger  in  case  of  emergency. 

The  manifestations  of  tetany  in  parathyroidectomized  dogs  have 
failed  to  appear  or,  when  present,  have  ceased,  at  least  temporarily, 
in  case  of  operative  procedures  on  the  tibia  or  similar  operations  (Thomp- 
son and  Leigh  ton).  Guleke  observed  in  experiments  on  cats  and  dogs 
that  tetanic  attacks,  following  simultaneous  extirpation  of  the  para- 
thyroids and  thyroid,  ceased  on  removal  of  the  adrenals,  and  did  not 
recur  up  to  the  time  of  the  animal's  death.  Injections  of  adrenahn 
caused  the  spasms  to  reappear.  In  some  of  the  experiments,  ligation 
of  the  veins  of  the  adrenals  was  substituted  for  extirpation  of  the 
adrenal  glands.  The  result  was  cessation  of  the  attacks,  but  recurrence 
after  a  time.  At  autopsy,  the  blood  circulation  was  found  completely 
reestablished  through  anastomosis.  Whenever,  in  these  experiments,  a 
small  portion  of  thyroid  was  left  in  the  animal,  though  the  spasms  ceased 
after  removal  of  the  adrenals,  they  recurred  after  a  short  latent  period. 
The  effect  of  the  thyroid  on  the  existence  of  tetany  is  similar  to  that  of 
the  adrenals,  but  not  so  pronounced.  From  this  series  of  experiments 
it  was  concluded  that,  beside  the  antagonism  between  the  parathyroids 
and  the  adrenals,  there  exists  a  similar  antagonism  between  the  para- 
thyroids and  the  thyroid.  Very  likely  the  secretion  of  the  thyroid  gland 
excites  the  sympathetic  similarly  as  the  secretion  of  the  adrenals,  while 
the  parathyroids  hold  both  organs  in  equilibrium. 

That  the  secretion  of  the  thyroid  has  an  exciting  effect  on  the 
sympathetic  is  supported  by  the  investigations  of  Kraus,  Eppinger, 


522  REGIONAL   SURGERY 

Kostlivy,  et  al.  The  relationship  which  Guleke  has  observed  among  the 
parathyroids,  the  thyroid  and  the  adrenals  is  quite  well  confirmed  by 
the  hterature. 

A  schema  by  Eppinger,  Falta  and  Rudinger  indicates  their  view  of 
the  correlationship  existing  among  the  pancreas,  thyroid  and  adrenals 
(chromaffin  system).  These  investigators  maintain  that  the  thyroid 
and  the  chromaffin  system  have  a  reciprocal  advancing  influence  on 
each  other,  while  the  pancreas  experiences  a  pronounced  inhibition 
from  both. 

Convinced  by  his  own  observations  and  drawing  support  from  the 
investigations  of  others,  Guleke  inserts  the  parathyroids  into  the  schema 
of  Eppinger,  Falta  and  Rudinger.  The  following  reproduction  of 
Guleke's  schema  clearly  explains  this  author's  view.  Assuming  that 
future  investigations  will  confirm  the  results  of  Guleke's  experiments 
showing  the  important  role  of  the  adrenals  in  the  tetany  of  thyroid — 
parathyroidectomized  animals,  a  path  seems  indicated  along  which 

Thyroid 


Pancreas  <!. ...  i \  Parathyroids 


Chromaffin  system^ 

much  may  be  gathered  for  a  more  comprehensive  view  of  this  disease. 

Pathology. — Pathologic  conditions  of  the  parathyroids  which  have 
been  reported  are  hemorrhage,  degenerative  and  progressive  changes, 
cystic  degeneration,  retention  cysts,  amyloid  infiltration,  chronic  fibrous 
parathyroiditis,  syphiUs,  tuberculosis  and  tumors  (Figs.  290  and  291.) 
Neoplasms  are  rare.  v.  Verebely  classifies  the  tumors  into  two  groups: 
(i)  extrathyroidal;  (2)  intrathyroidal.  Tumors  have  been  reported  by 
de  Santi,  MacCallum,  Hulst,  Da  Costa,  et  al.  Microscopic  examination 
has  been  necessary  to  diagnose  the  tissue  as  parathyroidal.  Only  local 
symptoms  have  been  noted.  A  few  cases  of  tuberculosis  of  the  para- 
thyroid have  been  observed  (Benjamins,  Verebely,  Eggers,  Winter- 
nitz,  et  al.).  Tetany  associated  with  this  condition  has  been  reported. 
Verebely  remarks  that,  like  other  organs,  these  glandules  can  be 
affected  by  poisons  through  the  blood  stream  or  from  neighboring  organs. 

Clinical  Symptoms. — The  symptoms  of  tetany  are  manifold  and 
the  individual  forms  show  the  greatest  variety  in  the  location  of  the 
spasms.     The  ''obstetrical  hand"  is  a  typical  position.     In  children, 

^  The  neighboring  parts  affect  each  other  antagonistically;  the  opposite  parts  in  an  ad- 
vancing manner. 


THE    PARATHYROIDS 


523 


especially,  the  fingers  may  be  separated  and  only  the  terminal  phalanges 
flexed.  The  feet  may  assume  the  position  of  equinus  or  equinovarus. 
Dyspnoeic  disturbances  are  frequently  met.  Laryngospasm  is  often  a 
predominating  symptom  in  children.     The  duration  of  attacks  varies 


Fig.  290. — Photomicrograph  of  tumor  nodule  showing  resemblance  to  parathyroid  glandule 
structure.     X   150.     {Thompson  and  Harris.) 

from  a  few  minutes  to  several  hours,  the  free  interval  from  a  few 
moments  to  days  or  weeks.  The  patient  generally  rests  during  the 
night.  The  sensorium  is  usally  free  in  the  adult,  but  in  severe 
cases  even  complete  loss  of  consciousness  may  be  present.     Besides  the 

B. 


Fig.  291. — Small  area  of  a  parathyroid.  Tetany  aj;e  5  mos.;  C,  small  dark  cells  of  the 
center;  D,  zone  of  development  showing  large  light  cells  which  are  absent  at  B,  replaced 
by  blood  cysts  (old  hemorrhages).     {Haberjeld.) 

spasms,  the  most  important  cardinal  symptom  of  tetany  is  the  increase 
of  the  electrical  irritability.  This  hyperexcitability  affects  chiefly  the 
motor  nerves  (Erb),  but  the  sensory  and  also  the  cranial  nerves  are 
similarly  affected.     There  is  marked  increase  of  galvanic  irritability. 


524  REGIONAL    SURGERY 

Increased  reaction  to  the  faradic  current  is  far  less  constant.  For  the 
test,  in  the  adult  the  nervus  ulnaris,  in  the  child  the  nervus  peronaeus 
is  employed. 

ErV s  Phenomenon. — This  may  be  present  in  most  of  the  motor  nerves 
which  are  available  for  the  test.  It  is  considered  the  most  important 
symptom  of  tetany,  since  no  other  condition  is  known  in  which  it  is 
present.  During  the  free  intervals  of  chronic  tetany  the  galvanic 
excitability  approximates  the  normal. 

Hoffmann's  Test. — The  sensory  nerves  show  an  increased  excitability 
toward  the  electrical  current.  The  ulnar  nerve  is  usually  tested. 
Parasthesia  of  the  supplied  area  occurs.  Chvostek,  Jr.,  found  sensory 
reaction  of  the  nervus  acusticus;  v.  Frankl.-Hochwart,  of  the  sense  of 
taste,  by  means  of  the  galvanic  current. 

Chvostek's  Test.- — Tapping  over  the  area  of  distribution  of  the 
facial  nerve.  Facial  twitchings  are  the  manifestation  of  tetany.  This 
test  is  valuable  because  of  its  technical  simplicity,  v.  Frankl-Hoch- 
wart  differentiates  three  grades  of  the  phenomenon,  according  to  the 
intensity.  The  phenomenon  is  very  frequently  present  in  tetany,  yet 
even  in  pronounced  cases  it  can  be  absent  and  often  shows  great  fluc- 
tuations (Falta).  The  light  degrees  are  seen  in  numerous  cases  of 
neurasthenia,  hysteria,  and  epilepsy,  v.  Frankl.-Hochwart  and  Schles- 
inger  found  Chvostek  II  and  III  in  nearly  half  of  the  patients  with 
pulmonary  tuberculosis,  and  in  many  of  these,  caseation  of  parathy- 
roids was  present.  This  symptom  is  noted  frequently  in  rachitis  (Falta) . 
The  phenomenon  is  particularly  frequent  in  all  possible  kinds  of 
cachexia,  especially  if  this  is  accompanied  by  loss  of  water  in  the  body. 

Trousseau's  Phenomenon. — Pressure  on  a  nerve  trunk  of  an  ex- 
tremity. The  result  is  a  typical  tetanic  attack  in  the  area  supplied  by 
the  nerve.  This  phenomenon  has  nothing  to  do  with  alterations  in 
the  circulation,  but  rests  on  the  excitability  of  the  nerve  itself  (v. 
Frankl.-Hochwart).  The  sign  is  demonstrable  in  two-thirds  of  all 
cases  of  tetany.  Schlesinger  states  that  a  mixed  nerve  is  necessary  for 
this  phenomenon.  The  coincidence  of  epileptic  attacks  with  tetany  is 
not  rare  (v.  Frankl.-Hochwart,  Freund,  et  al.).  Tetany  is  to  be  differ- 
entiated from  tetanoid  manifestations,  especially  hysterical.  In  hysteria, 
the  reaction  to  Trousseau's  sign  is  sudden;  in  tetany  it  is  gradual. 

Treatment. — The  occurrence  of  tetany  following  operation  on  the 
thyroid  is  today  rare  in  the  hands  of  the  experienced.  This  result  is 
due  to  improved  operative  technique  which,  in  turn,  is  based  on  a  more 
exact  knowledge  of  the  usual  and  also  exceptional  topography  of  the 


THE    PARATHYROIDS 


525 


parathyroidal  tissue.  In  52  cases  of  thyroidectomy  in  the  Billroth 
Clinic  tetany  occurred  12  times  (23  per  cent.)-  Nine  of  the  12 
patients  died,  .two  developed  chronic  tetany,  and  one  recovered.  In 
1890  von  Eiselsberg  stated  that  30  cases  of  tetany  had  been  observed 
following  extirpation  of  the  thyroid.  Of  these,  seven  are  said  to  have 
recovered,  three  became  chronically  affected,  and  13  died.  Re- 
sults in  the  remaining  cases  unknown  (cited  by  Halstead).  Halstead 
states  that  a  number  of  cases  of  post-operative  tetany  have  been  ob- 
served, some  of  them  for  years,  by  various  surgeons.  Failure  of 
tetany  to  develop  in  those  cases  in  which  total  thyroidectomy  had  been 
performed  with  ligation  of  both  thyroid  arteries  is  explained  on  the 
basis  that  the  existence  of  an  anterior  and  posterior  pharyngeal  arterial 
anastomosis  sufficed  to  insure  the  vitality  of  the  parathyroids  (Gins- 
burg).  Haberfeld  et  al.  have  demonstrated  hjrpoplasia  of  the  para- 
thyroids traceable  to  hemorrhage  resulting  from  pressure  and  conges- 
tion during  birth.  In  some  such  cases  the  absence  of  valves  in  the  para- 
thyroidal veins  has  been  noted  and  considered  contributive  to  the 
hemorrhage.  The  existence  or  absence  of  this  hypoplasia  cannot  be 
determined  at  operation,  therefore,  preventive  treatment,  in  the  form 
of  careful  surgical  technique  in  operative  procedures  on  the  thyroid,  is 
the  first  consideration.  In  our  experience,  by  performing  thyroid- 
ectomy within  the  capsule  and  bearing  in  mind  the  parathyroidal  zone, 
we  have  been  successful  in  avoiding  the  untoward  effects  of  injury  to 
these  little  bodies.  During  this  operation  the  parathyroids  are  rarely 
seen.  Any  tissue  removed,  which,  in  the  slightest  degree,  suggests  these 
glandules,  is  immediately  implanted  on  the  remaining  thyroid  beneath 
the  capsule  in  a  cavity  free  from  hemorrhage.  In  general,  the  results 
of  treatment  of  tetany  have  not  been  very  satisfactory.  The  effect  of 
the  usual  sedatives  is  frequently  nil.  Successes  have  been  reported 
from  the  employment  of  venesection  (Levi)  and  lumbar  punctures 
(Narbut).  MacCallum  and  Voegtlin  have  demonstrated  the  value  of 
certain  salts,  particularly  those  of  calcium.  The  method  of  adminis- 
tration is  either  intravenous  or  in  large  doses  by  mouth.  The  effect 
is  admittedly  transitory..  MacCallum  has  reported  benefit  resulting 
from  the  intravenous  injection  of  parathyroidectomized  dogs  with 
very  large  amounts  of  the  prepared  parathyroids  of  the  same  species. 
Branham  cites  a  recovery  following  the  employment  of  an  emulsion  of 
fresh  parathyroids  in  a  case  of  tetany  after  thyroidectomy.  The 
treatment  seemed  to  tide  the  patient  over  until  the  injured  parathyroidal 
tissue   regained   its   normal   condition.     The   use   of   Beebe's   nucleo- 


526  REGIONAL   SURGERY 

proteid  is  supported  by  many.  Halstead  has  reported  an  interesting 
case  of  post-operative  tetany  which  was  apparently  benefited  after 
several  months  from  treatment  with  the  dried  parathyroids  of  beeves. 
The  reported  results  from  treatment  of  tetany  with  the  extract  of  thy- 
roid are  rather  generally  viewed  with  scepticism.  The  results  of  trans- 
plantation of  the  parathyroids  are  divergent,  but  the  history  of  this 
phase  of  the  subject  contains  successes  sufficiently  supported  to  stimu- 
late encouragement  and  painstaking  research.  A  reserve  functional 
power  of  organs  in  general  is  now  a  recognized  fact.  The  amount  of 
this  reserve  varies  in  different  structures,  but  a  conservative  average 
would  be  four  to  six  times.  It  has  been  experimentally  shown  (Hal- 
stead)  that  a  very  small  portion  of  parathyroidal  tissue  suffices  for  main- 
taining the  function  of  these  glandules.  It  is  probable  that  in  the 
normal  state  of  the  body  one  active,  at  least  hyperplastic,  parathyroid 
would  suffice.  Pool  and  others  made  the  important  observation  that 
compensatory  hypertrophy  of  the  remaining  parathyroidal  tissue  re- 
sulted where  one  glandule  has  been  removed.  The  probability  of  this 
compensatory  process  occurring  should  be  considered  in  attributing  to 
therapeutic  measures  the  good  results  in  tetany  following  operations 
on  the  thyroid.  It  has  been  demonstrated  that  parathyroidal  tissue, 
which,  though  hypoplastic,  is  functionally  sufficient  under  normal  con- 
ditions of  the  body,  may  become  relatively  insufficient  in  the  presence 
of  some  intercurrent  disturbance.  In  this  potential  state  of  tetany 
strict  attention  to  the  general  condition  of  the  body  is  indicated.  It 
has  been  stated  by  several  authors  that  of  fundamental  importance 
and  as  effective  as  any  measures  in  the  treatment  of  the  disease  are  rest 
in  bed,  a  diet  very  limited  in  meat,  frequent  warm  baths  and  tonics. 
The  effect  of  gastroenterostomy  on  gastric  tetany  is  noteworthy.  In 
21  operated  cases,  17  remained  cured  (Wirth).  Some  recommend  im- 
mediate operation,  others  prefer  to  await  the  results  of  internal  treat- 
ment. Positive  pyloric  stenosis  is  the  indication  for  gastroenterostomy 
(Falta),  but  the  rather  frequent  simulations  of  this  condition  must  be 
considered  and  excluded.  Ina  series  of  8,500  operations  for  goiter  in  this 
cHnic,  one  case  presented  manifestations  of  tetany.  The  condition 
subsided,  leaving  doubt  as  to  its  true  nature.  The  extract  of  thyroid 
and  other  measures  were  employed,  but  their  effect  was  questionable. 
Summary. — Investigations  on  the  problem  of  the  parathyroids  have 
been  various,  very  extensive  and  by  numerous  observers.  An  im- 
pressive fact  to  be  learned  from  an  analysis  of  the  work  is  the  rather 
wide  divergence  in  results,  theories  and  opinions  among  men  of  equally 


THE   PARATHYROIDS  527 

high  standing  in  the  profession.  Viewed  in  this  Hght,  the  parathyroids 
must  be  held  as  structures  concerning  which  Httle  knowledge  that  is 
exact  exists.  It  would  seem  that  many  experimentalists  have  entered 
the  field  of  the  parathyroids  with  minds  that  were  prejudiced  by  a 
preconceived  theory  or  opinion.  Scientific  essentials  in  the  form  of 
parallelism  of  factors  have  not  been  duly  heeded,  resulting  in  dis- 
cordant deductions  because  of  inharmonious  premises.  Our  knowledge 
of  increased  activity  of  the  parathyroidal  tissue  is  practically  nil. 
No  manifestations  of  hyperactivity  of  these  glandules,  even  in  the 
presence  of  hypertrophy  or  adenoma,  have  been  observed.  Though 
the  parathyreoprivous  theory  of  tetany  has  its  adversaries,  still  the 
summation  of  experimental  work  presents  a  preponderance  of  evidence 
showing  that  an  extensive  loss  of  the  parathyroidal  tissue,  destruction 
or  serious  injury  of  its  blood  supply  may  produce  tetany.  It  is  a  note- 
worthy fact  that  in  all  reported  cases  of  tetany  following  operations 
on  the  thyroid  in  the  human  being,  there  has  been  great  reduction  of 
the  glandular  tissue  of  the  thyroid.  Usually  both  lobes  have  been 
operated  upon,  the  portion  left  being  injured  in  its  blood  supply  and 
venous  return,  which  evidently  carries  a  large  amount  of  glandular 
secretion.  Though  not  themselves  removed,  the  parathyroids  may 
suffer  a  great  loss  in  their  blood  supply,  which  may  later  be  restored. 
Repair  of  this  nature,  likewise  compensatory  hypertrophy  of  remaining 
parathyroidal  tissue,  may  explain  many  recoveries  from  tetany  which 
have  been  ascribed  to  therapeutic  measures. 

REFERENCES 

Beebe:  Proceedings  of  the  Soc.  for  Exper.  Biul.  &'Med.,  I\',  p.  64,  1907. 

Benjamins:  Beit.  zur.  path.  Anat.,  XXXI,  143,  1902. 

Berkeley:  Med.  News.  Dec.  2,  1905. 

Biedl:  Innere  Sekietion,    1913.     Wien.   Klinik,    1910. 

Branham:  Ann.  Surg.,  1908,  XLMII,  161-164. 

Chvostek:  Wein.  klin.  Woch.,  1907,  XX,  p.  625. 

Chvostek,  Jr.:  Diagnose  und  Therapie  der  Tetanic,  D.  m.  \V.,  1909.  XXX \'.  825. 

DaCosta:  S.  G.  &  O.,  1909,  VIII,  pp.  32-36. 

Eggers:  Chicago  Path.  Soc,   1907,  VII,  102. 

V.  Eiselsberg:  Beitr.  z.  Chir.,  Billrolh-Festschr.,  Stuttgart,  1892. 

Eppinger:  Wien.  klin.  Worh.,  igcS.  XXI,  752 

Erb:  Arch.  f.  Psych.,  4,  271,  1S74. 

Erdheim:  Beit.  zur.  path.  Anat.,  XXXV,  366.  1904. 

Escherich:  Wien.  kHn.  Woch.,  1907,  XX,  969. 

Evans:  Ann.  of  Surg.,  Oct.,  1907,  XL VI,  489-506. 

Falta:  Die  Erkrankungen  der  Blutdriisen,   191 3 

Freuxd:  Deut.  Arch.  f.  klin.  Med.,  76,  1903. 


528    .  REGIONAL   SURGERY 

Friedenthal:  cit.  Guleke,  Arch,  f.klin.  Chir.,  Bd.  94,  Heft  3. 

Guleke:  Arch,  f,  klin.  Chir.,  Bd.  94,  Heft  3. 

Getzowa:  Virch.  Arch.,  CLXXXVIH,  1907,  p.  181. 

Ginsburg:  J.  A.  M.  A.,  June  i,  1912. 

Gley:  Comptes  Rendus  de  laSoc.de   Biol.,  1891-1895-1897.     Archiv  de  Phys., 

1892-3.     Arch.  f.  die  gesammte  Phys.,  Feb.,  1897.     Brit.  Med.  Jrnl.,  Sept. 

21,  1901,  771. 
Haberfeld:   Separatabdruck  aus  Virch.,  Arch.  f.  path.   Anat.  und  Phys.   und 

f.  klin.  Med.,  Bd.  203,  1911. 
Halstead:  Ann.  of  Surg.,   Oct.,  1907.  pp.  489-506.     Am.  Jrnl.  Med.  Sci.,  July, 

1907.    Soc.  Exper.  Biol.  &  Med.,  V,  pp.  74-77,  1908. 
Hess:  cit.  Guleke,  Arch.  f.  klin.  Chir.,  Bd.  94,  Heft  3. 
HocHWART,  V.  Frankl.:  Deut.  Klinik,  VI,  I,  p.  933,  1906.     Wien.  med.  Woch., 

1906,  p.  310.     N.  Y.  Acad,  of  Med.,  May  2,  1907. 
Hoefman:  Jrnl.  Deut.  Arch.  f.  klin.  Med.,  Bd.  XLIII,  1888. 
Hulst:  Cent.  f.  Path.  Anat.,  XVI,  103,  1905. 

Jeandelize:  Lundgurg.,  Zeit. f.  Nervenheil-Kunde,  XXVII,  H.  3  and  4,  217,  1904. 
Kocher:  Arch.  f.  klin.  Chir.,  XXIX,  255. 
Kostlivy:  cit.  Guleke,  Arch.  f.  klin.  Chir.,  Bd.  94,  Heft  3. 
Kraus:  cit.  Guleke,  Arch.  f.  'klin.  Chir.,  Bd.  94,  Heft  3. 
Levi:  cit.  Falta,  Die  Erkrankungen  der  Blutdriisen,  1913. 
Lundborg:  Deut.  Zeit.  f.  Nervenheilk,  XXVII,  p- .748,  1904. 
MacCallum:   Med.  News,  LXXXIII,  820,  1903.     Cent.  f.  allg.  Path,  u.  path. 

Anat.,  XVI,  No.  10,  386, 1905.     Med.  News, LXXXVI,  1905.     Johns  Hopkins 

Hospital  Bulletin,  Sept.,  1907. 
MtJLLER:  Beit,  zur  path.  Anat.,  XIX,  127,  1896. 
Narbut:  Zeit.  Zentralbl.  f.  Chir.,  1907,  1147. 
PiNELEs:  Deut.  Arch.  f.  klin.  Med.,  LXXXV,  p.  491,  1905. 
Pool:  Ann.  of  Surg.,  Vol.  XL VI,  pp.  507-537. 
Reverdin:  Ref.  Alquier.,  Gazette  das  Popitaux,  Nov.  10,  1906. 
Rogers  and  Ferguson:  Am.  Jrnl.  Med.  Sci.,  CXXXI,  p.  811,  1906. 
RousSY  ET  Clitnet:  Les  parathyreoides  dans  4  cas  de  M.  de  Parkinson,  Compt. 

rend.  Soc.  Biol.  7,  1910. 
Rudinger:  Zeit.  f.  exper.  Path.  u.  Pharm.,  5,  1908. 
DE  Santi:  Internat.  Cent.  f.  Laryngol.  u.  RhinoL,  546,  1900. 
Sandstrom:  Lakareforenings  Forhandlingar,  Upsala,  1880. 
Schilder:  cit.  Guleke,  Arch.  f.  klin.  Chir.,  Bd.  94,  Heft  3. 
Schlesinger:  Neurol.  Zentralbl.,  1892,  66. 

Thompson  and  Leighton:  Jrnl.  Med.  Research,  1909,  XXI,  pp.  135-148. 
Trousseau:  Falta,  Die  Erkrankungen  der  Blutdriisen,  1913. 
Verebely:  Virch.  Arch.,  CLXXXVII,  80,  1906. 

Voegtlin:  Johns  Hopkins  Hosp.  Bulletin,  1908,  Vol.  XIX,  pp.  91-92. 
Welsh:  Jrnl.  of  Anat.  and  Phys.,  XXXII,  292  and  380,  i8g8. 
WiNTERNiTz:  Johns  Hopkins  Hosp.  Bull.,  1909,  XX,  269. 
Wirth:  cit.  Falta,  Die  Erkrankungen  der  Blutdriisen,  19 13. 
Yanase:  Wien.  klin.  Woch.,  1157,  1907. 


SECTION  XXI 

THE  THYMUS 

By 

CHARLES  H.  MAYO,  A.  M.,  LL.  D.,  F.  A.  C.  S., 
Rochester,  Minn. 

The  thymus  was  originally  designated  as  a  mere  component  of  the 
lymphatic  apparatus,  but  the  evidence,  which  has  accumulated  since 
Plater  first  discussed  the  so-termed  "  thymic  death"  in  1614,  is  sufficient 
to  prove  that  this  gland  belojigs  to  the  organs  of  internal  secretion.  To 
the  extensive  investigations  of  Friedleben,  Hammar,  Maximow,  v. 
Sury,  Schridde,  Ronconi,  Pappenheimer,  Hart,  Klose  and  Vogt,  Matti, 
Tandler,  Vincent,  etal.,  are  we  indebted  for  the  advancement  which  has 
been  made  in  our  knowledge  of  the  thymus.  Results  and  deductions 
from  the  various  investigations  present  considerable  divergency,  but 
from  the  summation  of  these  contributions  a  substantial  step  forward 
has  been  taken  toward  the  solution  of  the  problem. 

Embryology. — The  thymus  arises  as  a  paired  organ  from  the  ventral 
portion  of  the  third  branchial  cleft.  This  is  the  principal  anlage,  but 
it  is  maintained  by  some  that  there  is  also  a  rudimentary  outgrowth  from 
the  ventral  wall  of  the  fourth  branchial  cleft  (Fig.  292.)  Since  also  the 
parathyroids  arise  partly  from  the  third  and  the  lateral  thyroid  from 
the  fourth  branchial  cleft  the  thymus  is  at  least  topographically  closely 
associated  with  these  glands  during  development.  At  birth  the 
thymic  gland  lies  behind  the  sternum,  extending  downward  to  the 
pericardium  and  upward  somewhat  above  the  incisura  jugularis. 

Histology. — Hammar  defines  the  thymus  as  an  "epithelial  organ, 
which  is  permeated  with  lymphocytes."  The  gland  is  therefore, 
viewed  as  of  entodermal  origin,  with  a  secondary  ingrowth  of  mess- 
dermal  structure.  However,  with  regard  to  the  origin  of  the  lymphatic 
elements  a  wide  diversity  of  opinions  still  exists.  Stohr  assumes  their 
origin  to  be  from  a  division  of  the  epithelial  portion.  The  entodermal 
origin  of  the  reticulum  cells  and  of  the  Hassal  bodies  is  well  supported 
by  the  examinations  of  Hammar. 

Two  phases  in  the  existence  of  the  thymus  are  recognized:  (i)  pro- 
gression; (2)  regression.     A  variety  of  views  exists  as  to  the  various 
34  529 


530 


REGIONAL   SURGERY 


incidents  in  these  phases  of  the  gland.  The  prevailing  opinion  is  that 
the  weight  of  the  organ  continues  to  increase  aiter  birth  and  ceases 
normally  only  at  the  time  of  puberty  (Hammer,  v.  Sury,  Schridde, 
Ronconi,  Pappenheimer,  et  al).  During  this  physiologic  involution 
the  thymic  tissue  gradually  atrophies  and  is  partly  replaced  by  fat. 
The  older  view,  that  the  glandular  structure  completely  disappears 
early  in  life,  is  not  now  accepted.     Remnants  of  thymic  structure  are 


TuCtuS     •th.yo-.O- 

pKa'-y-vgeus 


Ae^ophiii^us 


Fig.  292. — The  anlages  of  the  thymus  and  thyroid  of  a  human  embryo,  18.5  m.m. 

behind.     {After  Kollmanji.) 


View  from 


commonly  seen  even  in  the  very  old.  Hammar  observed  mitotic  in- 
crease of  lymphocytes  and  new  formation  of  Hassal  bodies  in  the 
later  years  of  life.  Perhaps  one  of  the  most  fertile  sources  of  error  in 
estimating  the  various  phases  of  the  thymus  is  failure  to  appreciate  the 
causes  and  frequency  of  "accidental  involution."  Wharton  (1659) 
observed  this  involution  in  animals  after  excessive  exertion.  Fried- 
leben  and  later  Hammar  noted  a  similar  effect  in  starving  animals. 
Hart  emphasizes  the  causal  role  of  the  common  infectious  diseases  of 
childhood  in  atrophic  changes  of  the  thymus.     Accidental  involution 


THE   THYMUS  53 1 

is  found  in  many  chronic  diseases  which  lead  to  marasmus  (Falta). 
The  results  of  all  investigations  agree  on  the  pronounced  sensitiveness 
of  the  lymphatic  elements  to  X-rays.  The  epithelial  portion  of  the 
gland  proves  to  be  more  resistant  and  assumes  the  active  role  of  phago- 
cytosis. Rudberg  has  observed  regeneration  of  the  thymic  elements 
after  the  thymus  had  been  exposed  to  X-rays.  Heineke  had  already 
noted  relatively  rapid  restoration  of  the  lymphoid  tissue  in  the  lym- 
phatic glands,  spleen  and  the  marrow  of  bones.  Friedleben  states 
that  complete  regeneration  of  the  thymus  can  occur,  as  shown  in  animals 
which  had  been  reduced  nearly  to  inanition  and  then  re-fed  to  over- 
weight. The  question  of  regeneration  after  disease  has  been  but 
limitedly  investigated  and  little  discussed. 

Anatomy. — Obviously,  the  size  and  weight  of  the  thymus  varies 
with  the  period  of  its  existence.  The  figures  reported  by  different  in- 
vestigators vary  within  wide  Hmits.  In  495  patients  under  five  years 
of  age,  Howland  found  the  average  thymic  weight  4  to  6  gm.  Dud- 
geon's estimate  is  5  to  7  gm.;  Klose's,  5  to  14  gm. 

The  thymus  is  of  grayish  red  color,  has  an  irregular,  fiat,  oblong 
shape,  and  consists  of  two  unusually  asymmetric  lobes— lobus  dexter 
and  lobus  sinister — united  only  by  a  loose  connective  tissue.  Each 
of  these  lobes  is  composed  of  a  large  number  of  small  lobules — lobtdi 
thymi — which  are  separable  from  one  another,  but  are  all  connected 
by  a  medullary  cord — tractus  centralis — which  follows  a  tortuous  course 
inside  the  thymus.  The  gland  lies  just  behind  the  sternum,  in  the 
^patium  mediastinale  anterior;  it  is  bounded  behind  by  the  upper  part 
of  the  pericardium,  the  vena  cava  superior,  venae  anonymae,  the  arcus 
aortse  and  its  branches;  laterally  and  partly  in  front,  by  the  pleura 
mediastinalis.  Above,  it  may  reach  behind  the  musculi  sternothyreoided 
as  far  as  the  glandula  thyreoidea.  Its  anterior  wall  is  loosely,  the  others 
more  firmly,  connected  with  the  surrounding  tissues.  The  thymus  is 
described  as  attached  to  the  thyroid  by  the  thyrothymal  or  suspensory 
ligaments. 

Physiology. — Since  Friedleben  (1858)  presented  his  extensive  work 
on  the  physiology  of  the  thymus  in  health  and  disease,  there  have  been 
numerous  contributions  by  many  investigators  on  this  phase  of  the 
subject.  Despite  this  fact,  in  reviewing  the  field  of  accomplishments 
one  is  forced  to  agree  with  Wiesel's  statement,  namely,  that  "the  prob- 
lem of  the  functional  importance  of  the  thymic  gland  is  almost  com- 
pletely unsolved."  Throughout  the  experimental  work  which  has 
been  done,  there  is,  at  least  in  many  of  its  phases,  an  impressive  lack 


532  REGIONAL   SURGERY 

of  uniformity  in  results.  The  main  modes  of  experimental  investiga- 
tion have  been  observations  on  the  effects  of  extirpation  of  the  thymus, 
hyperthymization,  and  the  relations  of  the  thymic  gland  to  the  other 
organs  of  internal  secretion.  Negligible  ill  effects,  transitory  and  per- 
sistent serious  disturbances  are  among  the  reported  experimental  re- 
sults from  removal  of  this  gland.  An  important  factor  in  this  divergence 
of  effects  is  diversity  in  the  period  of  thymic  existence  in  which  opera- 
tion was  performed.  Results  have  been  positive  and  rather  uniform 
when  extirpation  of  the  thymus  has  been  done  in  the  early  days  of  the 
animal's  life.  Another  source  of  erroneous  conclusions  has  been  the 
simultaneous  injury  of  other  structures,  as,  for  example,  the  parathy- 
roids. The  causal  role  attributed  to  the  thymus  in  tetany  is  probably 
ascribable  to  this  error.  The  most  important  and  generally  accepted 
sequence  of  experimental  thymectomy  is  disturbance  in  the  develop- 
ment of  the  skeleton  (Friedleben,  Basch,  Klose  and  Vogt,  Matti,  et  al.). 
This  is  manifested  by  a  diminution  in  the  length  and  weight  of  the 
bones,  also  by  a  pronounced  softness,  pliantness  or  frangibility.  This 
physiologic  deficiency  in  osseous  structure  results  in  defective  develop- 
ment, various  deformities,  and  fractures  with  non-union  because  of 
insufficient  callus  formation.  The  histologic  picture  is  atrophy  of 
bone.  Undissolved  calcium  is  diminished  about  one-half.  During 
the  period  of  osseous  growth  this  deficiency  of  calcium  conduces  to 
rachitis,  abnormal  flexibility  of  bone;  after  this  period  the  results  are 
osteomalacia,  and,  finally,  osteoporosis,  abnormal  frangibility.  Re- 
sultant motor,  sensory  and  cerebral  phenomena  have  been  described 
by  Klose  and  Vogt.  The  general  picture  of  these  manifestations  is  a 
duUing,  idiota  thymopriva  (Beidl).  Changes  in  the  condition  of  the 
blood  have  been  studied  by  several  investigators  with  various  results. 
The  decrease  in  haemoglobin,  erythrocytes,  and  leucocytes  observed 
by  some  has  been  found  to  be  transitory  by  others.  The  spleen  and 
the  pancreas  particularly  have  been  noted  enlarged.  The  splenic  hyper- 
trophy is  considered  compensatory  for  the  absent  thymus  (Klose  and 
Vogt).  Hyperplasia  of  the  thyroid  following  extirpation  of  the  thymus 
is  maintained  by  some  authors,  but  denied  by  others.  In  guinea-pigs 
Paton  observed  a  rapid  growth  of  the  testicles  following  thymectomy 
done  before  puberty;  after  this  period  the  operation  had  no  effect  on 
the  weight  of  these  structures.  The  observations  of  U.  Soli,  confirmed 
by  Lucien  and  Parisot,  disagree  with  those  of  Paton.  The  latter's 
results  are  supported  by  Klose  and  Vogt. 

In  the  absence  of  the  thyroid,  the  thymus  has  been  observed  en- 


THE    THYMUS  533 

larged  by  several  authors  (Cadeac  and  Guinard,  Gley).  Others  have 
reported  decrease  in  the  weight  of  the  thymus  after  extirpation  of  the 
thyroid.  Pronounced  thymic  atrophy  has  been  noted  in  the  case  of 
death  from  cachexia  thyreopriva.  After  thyreoparathyroidectomy 
an  increase  of  the  medullary  portion  of  the  thymus  at  the  expense  of 
the  cortical,  with  marked  hypera^mia  of  the  gland,  has  been  described 
(Pigache  and  Worms).  Where  atrophy  occurs  in  these  conditions,  the 
possibility  of  accidental  involution  is  to  be  considered.  Two  effects 
have  been  noted  from  feeding  with  thyroid:  hyperthyroidization,  an 
indirect  depressive  action  on  the  thymus,  manifested  by  general  dis- 
turbances of  nutrition;  and  a  direct,  specific,  exciting  effect.  The  re- 
sult is  dependent  on  certain  factors,  chief  of  which  is  the  amount  of 
thyroid  administered  (Utterstrom).  Hoskins  observed  increase  in 
size  of  the  thymus  in  the  offspring  of  guinea-pigs  fed  with  thyroid. 
The  hypertrophy  affected  principally  the  cortex.  Hoskins  considers 
the  enlargement  of  the  thymus  as  a  direct  stimulating  effect  of  the 
thyroid  hormone,  and  suggests  an  analogy  of  his  finding  with  the  thymic 
hypertrophy  observed  in  Basedow's  disease.  An  increase  of  the  weight 
of  the  thymus  occurs  after  removal  of  the  adrenals  (Boinet,  Calogero, 
Auld).  After  injections  of  extracts  of  the  cortex  and  medulla  of  the 
adrenals,  Wastenson  observed  a  diminution  .of  the  thymus.  The  in- 
fluence of  the  genital  glands  on  the  thymic  gland  is  most  important. 
Their  removal  is  followed  by  increase  in  weight  of  the  latter  organ 
(Calzalari).  This  effect  of  castration  has  been  mentioned  by  Hammar, 
Tandler  and  Gross.  Adler  injected  guinea-pigs  and  rabbits  with  ex- 
tract of  the  fresh  thymi  of  calves,  and  estimated  the  adrenahn-content 
of  the  blood.  A  constant  increase  of  adrenalin  was  observed  after  the 
preliminary  administration  of  thymic  extract.  The  author  interpreted 
this  to  indicate  that  the  adrenal  system,  by  an  increased  production  of 
adrenalin,  is  concerned  in  diminishing  or  abolishing  the  hypotonic  in- 
fluence of  the  thymus.  By  injecting  thymic  extract,  Yokoyama  has 
shown  that  the  effect  of  adrenalin  in  raising  blood  pressure  is  diminished 
or  prevented,  and  this,  the  author  believes,  is  a  proof  that  the  thymus 
acts  hypotonically.  Svehla  was  the  first  to  note  that  the  intravenous 
injection  of  an  aqueous  extract  of  the  thymus  produces  acceleration  of 
the  cardiac  beat  and  lowering  of  the  blood  pressure.  However,  Vin- 
cent and  Sheen  et  al.  emphasize  the  fact  that  similarly  acting  depressive 
substances  can  be  extracted  from  many  other  tissues.  These  circulatory 
disturbances  Popper  attributes  to  the  general  pecuUarity  of  tissue  ex- 
tracts in  producing  intravascular  clotting.     Biedl  states  that  this  effect 


534  "  REGIONAL   SURGERY 

of  the  thymic  extract  may  stand  in  relation  to  the  content  of  the  gland 
in  cholin.  The  results  of  implantation  of  the  thymus  have  been  in 
general  negligible. 

Pathology. — Among  the  conditions  which  have  been  reported  are: 
absence  of  the  gland;  changes  considered  post-mortal;  effects  of  the 
infectious  diseases  of  childhood,  over-exertion,  starvation;  circulatory 
disturbances;  acute  inflammatory  processes;  tuberculosis;  syphilis, 
neoplasms,  and  status  thymicus.  Absence  of  the  thymus  in  the  human 
is  rare.  Bourneville  reported  absence  of  the  gland  in  25  out  of  28 
mentally  weak  children.  Hart  (191 2)  has  pointed  out  the  degenerative 
effects  on  the  thymus  of  various  infectious  diseases,  particularly  the 
ordinary  diseases  of  childhood.  Hemorrhage  in  the  gland  is  not  in- 
frequent. It  has  been  observed  in  association  with  whooping  cough, 
measles,  hemophilia,  phosphorus  poisoning,  syphilis  and,  most  fre- 
quently, with  pneumococcic  infection.  Hyperaemia  occurs  with  re- 
spiratory and  circulatory  disturbance.  Some  authors  state  that  hyper- 
aemia follows  ligation  of  the  inferior  thyroid  artery  and  may  at  times 
cause  serious  effects.  Abscess  and  tuberculosis  of  the  thymus  are  usually 
secondary.  Syphilis  of  this  gland  is  rare.  It  is  usually  present  in  the 
form  of  diffuse  interstitial  inflammation.  Some  cases  of  gummata 
have  been  reported.  The  Dubois  abscess  is  considered  by  some  authors 
(Weisflog,  Schlesinger,  Chiari,  et  al.)  as  characteristic  of  lues.  Neo- 
plasms have  been  reported  by  several,  but  according  to  the  present 
view  the  history  of  thymic  tumors  needs  revision.  The  determining 
points  advanced  for  the  diagnosis  of  these  growths  are  position  and 
thymic  rests,  particularly  Hassall's  bodies.  The  gland  is  affected  by 
both  primary  and  secondary  tumors.  Neoplasms  of  epithelial  origin 
are  rare.  Carcinoma  is  considered  a  growth  from  the  epithelium. 
Tumors  of  the  connective-tissue  type  are  much  more  frequent  than  epi- 
thelial growths,  but  the  number  reported  has  diminished  under  closer 
analysis.  Lymphosarcoma  is  the  most  commonly  observed.  Sarcomas 
of  the  thymus  may  reach  a  very  great  size.  Cysts  are  found  under 
a  great  variety  of  pathologic  conditions.  Care  is  necessary  before 
designating  a  tumor  thymic. 

Status  Thymicus. — This  is  one  of  the  most  interesting  and  ex- 
tensively studied  phases  of  the  thymus.  In  a  recent  comprehensive 
work  on  the  pathology  of  this  gland,  Hart  concludes  as  follows :  "  There 
is  a  genuine  persistence  and  a  genuine  primary  hyperplasia  of  the 
thymus,  with  which  not  only  an  excessive  but  also  a  defective  function 
of  the  organ  is  frequently,  perhaps  even  always,  associated.     These 


THE   THYMUS 


53: 


are  an  expression  and  local  manifestation  of  an  abnormal  constitution, 
a  disturbance  of  equilibrium  in  the  polyglandular  system  of  organs  of 
internal  secretion,  on  the  basis  of  which  different  affections  can  de- 
velop. A  poisonous  effect  on  the  heart  appears  to  result  from  the  hyper- 
plastic thymus.  Up  to  the  present,  the  occurrence  of  a  genuine  status 
lymphaticus  has  not  been  proved.  The  swelHng  of  the  lymphatic 
apparatus  appears  much  more  to  show  a  tissue  reaction  dependent  upon 
the  thymus,  which  can  be  manifested  also  on  the  lymphoid  components 
of  the  thymus  itself.  There  occur  two  sharply  differentiable  histologic 
types:  the  so-called  medullary  hyperplasia,  which  presents  a  primary 


Fig.  293. — Case  40237  (exophthalmic  goiter)  Thymus-weight  38  G.     Autopsy  specimen, 

increase  of  the  specific  components  of  the  organ;  and  hyperplasia  of  both 
zones  in  somewhat  normal  proportions,  which  shows  a  secondary  increase 
of  the  non-specific  lymphoid  elements  in  a  mostly  primarily  hyperplastic 
thymus."  The  conditions  which  have  been  mostly  discussed  in  re- 
lation to  enlargement  of  the  thymus  are  the  so-called  thymic  death  and 
thymic  asthenia.  Hammar  states  that  only  a  few  of  the  cases  in  the 
literature  fulfil  the  essentials  for  determining  increased  size  of  the  gland. 
The  diagnosis  of  genuine  thymic  hyperplasia  is  difficult  and  a  source 
of  erroneous  deductions.  Certain  serious  disturbances  in  the  presence 
of  the  enlarged  gland  have  been  attributed  both  to  its  mechanical 
action  and  its  toxic  influence.  Today  the  mechanical  theory  for  sudden 
death  is  considered  by  most  authorities  as  untenable,  excepting,  per- 


536  REGIONAL   SURGERY 

haps,  for  isolated  cases  among  helpless  infants.  In  many  of  the  reports 
of  sudden  death  from  thymic  enlargement  the  presence  of  serious  con- 
ditions, for  example,  capillary  bronchitis  and  intestinal  diseases,  have 
not  been  duly  estimated.  On  the  other  hand,  anatomic  investigations 
and  the  results  of  thymectomy  support  the  view  that  considerable 
circulatory  and  respiratory  disturbances  may  be  caused  by  the  me- 
chanical effect  of  the  enlarged  thymus.  This  has  been  our  own  ex- 
perience. Despite  the  enormous  work  which  has  been  done  with 
regard  to  hyperthymization,  little  of  positive  knowledge  has  been 
acquired.  The  importance  of  thymic  hyperplasia  in  status  thymico- 
lymphaticus is  doubtful;     As  Biedl  remarks,  it  is  a  question  whether  the 


Fig.  294. — Low  power  photomicrograph  from  specimen  in  Fig.  293. 

enlargement  of  the  gland  forms  a  coordinated  local  manifestation  of  the 
constitutional  anomaly,  or  presents  only  a  subordinate  sequence  from 
anomalies  of  other  organs  of  internal  secretion  which  are  correlatively  as- 
sociated with  it.  Thymic  hyperplasias  are  found  in  cases  of  exophthalmic 
goiter  (Figs.  293,  294,  295,  296,  297,  298),  apparently  also  in  acromegaly^ 
pituitary  dystrophy,  myxoedema,  eunuchoidismus,  etc.  (Falta)-  Con- 
sequently, it  may  be  present  in  either  excessive  or  diminished  glandular 
function.  Caution  should  be  used  in  the  diagnosis  of  status  lymphat- 
icus.  Glandular  reactions  to  various  infections,  particularly  in  the  young, 
are  to  be  excluded.  To  the  pathologic  picture  of  status  thymico-lym- 
phaticus  belong,  beside  hyperplasia  of  the  thymus  and  the  lymphatic 
tissues,  cardiovascular  hypoplasia,  altered  sex-characteristics,  and  hypo- 
plasia of  other  structures,  for  example,  the  chromaffin  system.  The 
anatomically  demonstrated  association  of  non-tuberculous  Addison's 


THE    THYMUS 


537 


Fig.  295. — Case  41153  (exophthalmic  goiierj.     Thymus,  weight  40  g.  autopsy  specimen. 


Fig.  296. — Low-power  photomicrograph  from  specimen  in  Fig.  295. 


538 


REGIONAL  SURGERY 


disease  with  status  thymico-lymphaticus  or  status  lymphaticus  is  note- 
worthy. The  importance  attributed  by  some  to  the  occurrence  of  thymic 
persistence  or  hyperplasia  with  goiter  is,  in  the  present  Hght,  to  be  viewed 
with  scepticism.  Whereas  this  association  is  comparatively  frequently 
met,  yet,  even  in  some  cases  of  severe  exophthalmic  goiter,  the  amount 
of  thymic  tissue  present  is  almost  undiscernible  grossly.  Thus,  in  a 
series  of  12  autopsies  in  this  clinic  on  patients  with  goiter,  4  showed 
little  more  than  fatty  tissue  in  place  of  the  thymus,  while  the  remaining 


Fig.  297.^ — Case  43179  (exophthalmic  goiter.)     Thymus,  weight  55  g.     Autopsy  specimen. 


8  cases  presented  thymic  substance  varying  from  2  to  92  gm.  In  96 
autopsies  on  patients  with  other  conditions  the  thymus  was  notably 
enlarged  in  one  case.  Whereas,  in  these  examinations  the  gland  was 
prominently  persistent  or  hyperplastic  in  a  much  greater  percentage 
among  the  goiterous  cases  than  among  the  cases  with  other  conditions, 
yet  the  finding  was  not  sufficiently  constant,  and,  in  several,  the  amount 
of  thymic  tissue  too  inconsiderable  to  support  the  causal  role  attributed 
by  some  to  the  thymic  gland  in  goiter.* 

*Since  writing  the  above  a  review  of  the  necropsy  findings  has  been  made  in  62  cases 
of  exophthalmic  goiter  and  in  24  cases  of  simple  goiter.  Thirty  goiterous  individuals 
under  the  age  of  30  have  uniformly  shown  marked  thymic  hypertrophy  (7  non-operative, 
II  post-operative  exophthalmic  goiters,  and  2  post-operative  simple  goiters). 

Forty-three  patients  more  than  30  years  of  age  who  were  suffering  from  exophthal- 


THE    THYMUS 


539 


Clinical  Diagnosis. — The  diagnosis  of  enlarged  thymus  is  not  easy. 
Park  and  McGuire  maintain  that  from  anatomic  study  of  cases  at 
autopsy  the  methods  of  percussion  of  the  thymus  based  on  the  theory 
of  thymic  mobihty  are  founded  on  a  false  anatomic  hypothesis.     Occa- 


FiG.  298. — Case  41395  (.exophthalmic  goiter).     Low-power  photomicrograph  from  a  slightly 

enlarged  thymus. 

sionally  one  may  feel  the  thymus  if  the  patient  be  placed  in  the  prone 
position  and  palpation  made  in  the  suprasternal  notch.  Opinions  vary 
as  to  the  value  of  the  X-rays,  but  it  is  conceivable  that,  with  improved 
technique,  this  may  prove  to  be  a  reasonably  reliable  means  of  diagnosis 
(Figs.  299  and  300).     Continued  research  work  on  the  blood  and  the 


mic  goiter  were  examined.  In  1 2  the  onset  of  symptoms  was  before  the  age  of  30  and 
75  per  cent,  of  these  showed  marked  thymic  hypertrophy.  In  31  the  onset  occurred  after 
the  age  of  30  and  16  per  cent,  of  these  showed  marked  thymic  hypertrophy.  In  the 
22  necropsies,  in  cases  of  simple  goiter  (age  more  than  30),  there  were  9  per  cent,  with 
hypertrophied  thymus. 

We  have  not  been  able  to  confirm  certain  recent  observations  which  hold  that  thymic 
hypertrophy  is  associated  with  a  certain  severity  or  ty-pe  of  goiter  intoxication.  The  only 
relation  now  evident  is  the  uniform  presence  of  hj-pertrophied  thymus  in  young  individuals 
suffering  from  goiter,  and  a  fairly  definite  association  between  goiter  and  hypertrophy  of 
the  thymus. 


54P 


REGIONAL   SURGERY 


physiologic  and  pathologic  interrelationship  of  the  glands  of  internal 
secretion  may  result  in  valuable  aid  to  diagnosis.  A  child  presenting 
respiratory  difficulties  and  circulatory  disturbance  about  the  head  and 
neck  should  direct  attention  to  the  thymus,  in  the  absence  of  other  causal 


Fig.  299. — Case  No.  A56897.     Enlarged  thymus  confirmed  at  operation— X-ray  No.  12820. 

factors.  Tumors  of  the  thymus  grow  slowly,  and  the  first  signs  usually 
noted  are  those  due  to  respiratory  obstruction.  This  may  occur  sud- 
denly or  gradually  develop.  Other  signs  noted  are  those  resulting  from 
pressure  on  vessels  or  nerves.  Tumors  arising  from  neighboring  struc- 
tures may  be  misleading.     Lutelle  states  that,  in  general,  malignant 


THE   THYMUS 


541 


growths  of  the  anterior  mediastinum  are  thymic.  Metastasis  has  been 
commonly  observed  in  the  regionary  lymphatic  glands,  the  pleurae,  lungs, 
kidneys,  pancreas  and  spleen.  Positions  of  the  growth  and  thymic 
rests,  particularly  Hassall's  bodies,  are  given  as  the  determining  points 


Fig.  300. — No.  .^02^64.     Intra-thoracic  goiter  confirmed  at  operation — X-ray  Xo.  141J5. 

for  diagnosis  of  thymic  tumor,  but  the  absence  of  Hassall's  bodies  does 
not  positively  exclude  this  diagnosis. 

Treatment. — The  modes  of  treatment  which  have  been  recommended 
are  medical.  X-ray  and  operative.  The  effects  of  medication  must  be 
at  best  slow,  indefinite,  if  not  absolutely  negative.     The  results  from 


542  REGIONAL    SURGERY 

the  employment  of  the  X-rays  are  variously  reported.  Whereas  in 
some  cases  the  beneficial  effect  has  been  rapid,  in  others  it  has  been  slow, 
and  in  still  others  Rontgen  therapy  appeared  to  have  no  influence  on 
the  condition.  According  to  some  authorities,  the  good  results  may 
not  be  lasting.  To  say  the  least,  this  mode  of  treatment  is  indefinite 
and  rather  uncontrollable  in  its  action.  Oliver  states  that  the  operative 
treatment  of  h3^ertrophied  thymus  is  the  only  reliable  and  curative 
measure  that  can  be  applied.  This  author  reports  42  thymectomies 
with  23  cures.  The  operation  relieved  dyspnoea  in  25  out  of  28  cases, 
the  crises  of  suffocation  in  10  out  of  12,  and  the  stridor  in  12  out  of  16. 
There  were  15  deaths  in  the  42  cases,  most  of  which  occurred  through 
sepsis,  which  was  due  to  the  complications  of  tracheotomy  or  possibly 
to  difficulties  of  drainage.  Pedrazzini  prefers  chondrotomy  of  the  first 
costal  cartilage.  The  author  states  that  this  operation  is  simple,  re- 
lieves compression,  and  that  it  usually  has  to  be  done  as  an  emergent 
intervention.  Hart  maintains  that  tracheotomy  is  not  a  good  pro- 
cedure. Klose  and  Vogt  have  reported  eight  tracheotomies  which  were 
fruitless.  Chevalier  Jackson  extirpated  the  thymus,  with  permanent 
recovery,  after  having  secured  temporary  relief  with  tracheotomy.  Only 
one  case  (Konig)  has  been  reported  in  which  the  untoward  effects  of  in- 
sufficient thymic  function  followed  thymectomy.  It  may  be  that  this 
condition  is  not  more  frequently  observed  because  operation  is  done 
late  in  the  existence  of  the  gland.  However,  especially  in  the  infant, 
total  thymectomy  should  not  be  done;  a  portion  of  functional  glandular 
tissue  should  be  left  in  place.  The  subcapsular  operation  is  the 
procedure  of  choice. 

Operation. — A  curved  transverse  incision,  which  includes  skin  and 
platysma,  is  made  low  in  the  neck.  The  inner  borders  of  the  attach- 
ments of  the  sternomastoid  muscles  are  incised;  the  sternohyoids  are 
cut  across.  If  the  thymus  be  enlarged,  it  is  seen  as  a  pinkish  gland 
projecting  into  the  neck  from  behind  the  sternum.  The  gland  may 
now  be  caught  gently  with  clamps,  and  drawn  upon  until  the 
fingers  can  be  used  for  direct  traction.  The  vessels  are  not  large, 
the  fascia  which  incloses  the  gland  is  loose,  and  there  is  but  little 
difficulty  in  clamping  and  ligating  as  one  lobe  is  removed.  If  it  be 
deemed  necessary,  the  second  lobe  can  be  elevated  and  a  portion  of  it 
excised.  The  cure  is  complete.  A  drain  should  not  be  used  unless 
indications  for  drainage  are  urgent.  In  case  it  be  advisable,  a  folded 
strip  of  rubber  tissue  should  sufiice  for  the  few  hours  during  which 
drainage  may  be  necessary. 


THE    THYMUS  543 

Summary. — i.  The  thymus  is  an  organ  of  internal  secretion  and 
of  essential  importance  in  the  early  developmental  processes,  particu- 
larly in  those  of  the  osseous  system. 

2.  The  life  of  the  gland  consists  of  two  phases — one  of  progression, 
the  other  of  regression.  The  former  continues  to  the  time  of  puberty. 
Besides  the  physiological  involution,  accidental  involution  may  occur 
from  various  causes,  and  is  not  infrequent.  The  latter  form  of  in- 
volution has  been  a  source  of  error  in  estimating  the  gland.  Remnants 
of  thymic  tissue  are  commonly  present  in  adult  life,  even  in  the  latest 
years. 

3.  Hyperplasia  of  the  thymus  occurs,  but  the  question  of  h>'per- 
thymization  is  far  from  solved.  That  the  enlarged  gland  may  me- 
chanically cause  disturbance  is  accepted,  but  that  it  is  the  factor  in 
sudden  death,  excepting,  possibly,  in  isolated  cases  of  helpless  infants, 
is  sceptically  viewed. 

Respiratory  and  circulatory  disturbances  in  the  region  of  the  head 
and  neck,  particularly  in  children,  should  direct  attention  to  the 
thymus,  other  causal  factors  having  been  excluded. 

4.  Subcapsular  thymectomy  is  the  treatment  of  choice.  The 
operation  is  usually  not  difficult;  its  beneficial  effects  occur  early  and 
are  definite. 

REFERENCES 

Adler:  Virch.  Arch.  f.  Path.  Anat.  u.  Phys.  und  f.  Klin.  Med.,  1913,  Bd.  214, 
Hft.  I,  pp.  91-98. 

Auld:  Brit.  Med.  Jrnl.,  12,  May,  1894;  also,  Brit.  Med.  Jrnl.,  i,  pp.  1327,  1899. 

Basch:  Jahrb.  f.  Kinderh.,  1908,  Vol.  LXVIII,  pp.  668-691.  Also,  Amer.  Jrnl. 
Dis.   Child.,   Feb.,   1912. 

Biedl:  Innere  Sekretlon.     2  auflage.     i  toil,  1913. 

Boinet:  C.  r.  S.  B.,  47,  p.  162,  1895. 

Bourneville:  Progress.  Med.,  1900,  Vol.  XXIX,  p.  289. 

Cadeac  AND  Guinard:  C.  r.  S.  B.,  p.  468,  1894;  also  C.  r.  S.  B.,  p.  508,  1894. 

Calogero:  These  de  Paris,  1901;  C.  r.  S.  B.,  1903. 

Calzolari:  A.  i.  B.,  i,  S.  71,  1898. 

Chiari:  Verhandl.  d.  66.  Versamml.  deutsch.  Naturf.  u.  Arzte,  Vienna,  1894, 
2  teil,  2  Hiilfte,  p.  2;  Zeitschr.  f.  Heilk,  1894,  15. 

Dudgeon:  Brit.  Med.  Jrnl.,  1903,  \'ol.  II,  pp.  1533-36.  Trans.  Path.  Soc.  Lond., 
1904,  Vol.  LV,  pp.  151-203. 

Falta:  Jrnl.  Am.  Med.  Sci.,  April,  1909. 

Friedleben:  DiePhysiologie  der  Thymusdriise  inGesundheit  und  Krankheit,  vom 
Standpunkte  experimenteller  Forschung  und  klinischer  Erfahrung.  Frank- 
furt a.  m.,  1858. 

Gley:  C.  r.  S.  B.,  1891;  also,  C.  r.  S.  B.,  66,  1909,  p.  1017. 


544  REGIONAL   SURGERY 

Hammar:  Ergebnisse  der  Anat.  und  Entwicklung,  1909,  Vol.  XIX;  also,  Wien.  Med. 

Woch.,  1909,  Vol.  LIX,  pp.  2746,  2795,  2910. 
Hart:  Virch.  Arch.  f.  path.  Anat.  und  Phys.  und  f.  klin.  Med.,  1913,  Bd.  214,  Hft. 

I,  pp.  1-83. 
Heineke:  Mitt.  a.  d.  Grenzgeb.  d.  ]Med.  u.  Chir.,  1905,  p.  21. 
HosKiNS:  Am.  Jr.  Phys.,  26,  1910,  426-438. 
Howland:  Arch,  of  Pediatrics,  1907,  Vol.  XXIV,  p.  590. 

Jackson,  Chevalier:  Jrnl.  Am.  Med.  Assoc,  1907,  Vol.  XL VIII,  pp.  1753-1756. 
Klose  and  Vogt:  Arch.  f.  klin.  Chir.,  1910,  Vol.  XCII,  pp.  1125-1141 ;  also  Beitr. 

z.  klin.  Chir.,  1910,  Vol.  LXIX,  pp.  1-200. 
Konig:  Zentralb.  f.   Chir.,   1897,  Vol.  XXIV,  p.  605;   also,   Verhandl.  d.  deut. 

GeseUschaft.  f.  Chir.,  1906,  Vol.  XXXV,  p.  69. 
LuciEN  AND  Parisot:  Arch,  de  Med.  Exp.,  1910,  No.  10,  Vol.  XXII,  pp.  98-137. 
Lutelle:  Arch.  gen.  d.  a.  med.,  1890,  Vol.  CLXVI,  p.  641. 
McGuire  and  Park:  Arch.  Int.  Med.,  Sept.  15,  1912,  pp.  214-218. 
Matti:  Mitt.  a.  d.  Grenzgebieten  der  Med.  u.  Chir,,  1912,  Vol.  XXIV,  H.  4,  5,  pp. 

665-821 ;  also,  Deut.  Zeitschr.  f.  Chir.,  1912,  Vol.  CXVI. 
Maximow:  Arch.  f.  mik.  Anat.,  1909,  Vol.LXXIV;  1912,  Vol.LXXIX;  1912,  Vol. 

LXXX. 
Oli\t;er:  Jrnl.  de  Chir.,  Mch.,  1912,  pp.  233-246. 
Pappenheimer:  Jrnl.  of  Med.  Research,  22  (New  Ser.  17),  1910,  p.  i. 
Paton:  Jr.  of  Phys.,  42,  pp.  267-282,  1911. 

PiGACHE  AND  WoRMS :  Arch.  d'anat.  micr.,  12.     F.  2,  Sept.,  1910  (126). 
Plater:  Observat.  in  hominus  affectibus  plerisque,  etc.,  1614,  libritres  III,  p.  172. 
Popper:   Sitzungsb.  d.  k.  Akad.  d.  Wissensch.   Math-Naturw.  Kl.  Wien,    1905, 

Bd.  114,  S.  539  und  1906,  Bd.  115,  S.  201. 
RoNCONi:  Patologica,  1909,  p.  565  and  Estrato  delle  memorie  della  R.  accad.  d. 

scienze,  letters  ed  arti  Modena,  9,  ser.  3,  Appendize,  1909. 
Rudberg:  Arch.  f.  Anat.  u.  Entwickl.,  1907,  pp.  123,  134. 

Soli,  U.:  Comportamento  die  testicoli  negli  animali  stimizzati.     Policlinico,  1906. 
Schridde:  Zentralbl.  f.  allg.  Path.  u.  pathol.  Anat.,  1908,  p.  865.     Munch,  med. 

Woch.,  No.  48,  Nov.  26,  191 2,  pp.  2605-2608. 
Schlesinger:  Arch.  f.  Kinderheilk.,  1899,  Vol.  XXVI,  p.  205. 
Sheen,  W.,  Griffiths,  C.  and  Scholberg,  A.:  Lancet,  Nov.  4,  1911  (4154). 
StOhr:  Anat.  Hefte,  1906,  Vol.  XXXI,  pp.  407-457. 
SuRY,  v.:  Vierteljahrsschr.  f.  ger.  Med.,  3,  Folge.,  36,  1908,  S.  88. 
Svehla:  Arch.  f.  exper.  Pathol,  u.  Pharm.,  1900,  Vol.  XLIII. 
Tandler  and  Gross:  Die  Biologischen  Grundlagen  der  sekundaren  Geschlechts- 

charaktare,  1913. 
Utterstrom:  A.  m.  e.,  22,  p.  550,  1910  (127). 
Vincent:  Proc.  Physiol.  Soc.  Lond.,  1903,  Vol.  XXX,  p.  16. 
Wastenson:  cit.   Biedl.     Innere   Sekretion.     1913.     Erster  Teil. 
Weissflog:  Inaug.  Diss.,  Zurich,   i860. 
Wharton:  Adenographia;  Amsterdan,  1659. 
Wiesel:  Ergebnisse  der  pathol.  Anat.  v.  Lubarsch.  u.  Ostertag,    15.     Jahrg.,  2. 

Abt.,  1912,  pp.  416-782. 
Yokoyaiia:  Virch.  Arch.  f.  Path.  Anat.  u.  Phys.  u.  f.  Klin.  Med.,  1913,  Bd.  214,  Hft. 

1,  pp.  83-91. 


SECTION  XXII 

SURGERY  OF  THE  HEART,  PERICARDIUM 
AND  DIAPHRAGM 

By 

SAMUEL  ROBINSON,  A.  B.,  M.  D.,  F.  A.  C.  S. 
Mayo  Clinic,  Rochester,  Minx. 

The  surgery  of  the  heart  is  dangerous.  Experimental  investiga- 
tions of  the  past  few  years  have  demonstrated  methods  of  lessening 
these  dangers  not  only  through  the  construction  of  reliable  apparatus 
to  aid  the  impaired  respiratory  mechanism,  but  further  by  the  develop- 
ment of  elements  in  surgical  technique  which  will  in  the  future  lower  the 
mortality  of  chest  operations. 

Heart  Injuries. — Sudden  death  is  the  usual  sequel  to  gunshot  and 
stab  wounds  of  the  heart.  A  small  proportion  of  such  injuries  are  fol- 
lowed by  an  interval  of  considerable  length  in  which  time  surgical  aid 
should  be,  but  rarely  is,  seriously  considered.  The  gravity  of  symp- 
toms presents  a  picture  gruesome  and  horrible.  The  surgical  risk  is 
obviously  extreme.  General  surgeons,  no  one  of  whom  can  thus  far 
claim  any  particular  operative  experience  with  such  cases,  influenced 
undoubtedly  by  the  frequent  criminal  aspect  of  the  situation,  and  justly 
skeptical  as  to  the  surgical  outcome,  naturally  shrink  from  interfering, 
and  leave  the  patient  to  live  or  die  as  fate  may  decree.  The  victim  is 
already  dying  in  consequence  of  assault.  Operation  seems  for  the 
moment  like  a  repetition  of  the  crime,  and  surgeons  tend  to  leave  such 
situations  in  the  hands  of  God,  lawyers  and  police  officers. 

This  not  uncommon  attitude  should  cease,  and  the  results  accumu- 
lated by  responsible  writers  indicate  that  the  mortality  in  bullet  and 
stab  wounds  of  the  heart  is  lower  in  the  recorded  operated  cases  than 
in  those  left  to  their  natural  outcome.  Forty-live  per  cent,  of  the 
operation  cases  in  13  years  have  been  cured,  while  without  interference 
but  15  per  cent,  have  recovered. 

This  chapter  deals  with  heart  wounds.  At  least  three-quarters 
of  such  injuries  are  compHcated  by  trauma  to  the  pleura  and  lung.  The 
primary  element  in  the  management  of  thoracic  injury  from  knife  or 
35  545 


546  REGIONAL   SURGERY 

bullet  is  to  determine  whether  or  not  the  heart  is  perforated.  In  cases 
of  lung  or  pleural  trauma  without  heart  wound,  expectant  treatment  is 
generally  the  one  of  choice,  and  operation  may  readily  render  a  situa- 
tion fatal  which  might  have  pursued  a  favorable  course  if  expectantly 
treated. 

If,  however,  a  heart  wound  is  present  with  or  without  lung  injury, 
expectant  treatment  is  attended  with  the  greater  risk. 

Diagnosis. — With  rare  exceptions,  definite  diagnosis  of  cardiac 
wounds  is  impossible.  Heart  injuries  are  so  commonly  associated  with 
wounds  in  the  lung  and  pleura,  that,  although  the  latter  may  be  diag- 
nosed, uncertainty  invariably  exists  as  to  the  heart  involvement. 

A  small  proportion  of  stab  and  bullet  wounds  of  the  chest  are  con- 
fined to  the  heart,  and  such  cases  are  most  likely  to  be  correctly  diag- 
nosticated. Hemorrhage  from  the  heart  is  confined  to  the  pericardium 
and  the  anterior  mediastinum.  As  the  hemorrhage  increases,  the  peri- 
cardial opening  sometimes  becomes  occluded  and  the  condition  known 
as  "heart  tamponade"  arises.  As  the  intrapericardial  tension  increases 
and  the  heart  labors  against  it,  a  group  of  symptoms  develops  which 
is  almost  pathognomonic  of  the  condition:  pain  in  the  arm,  a  sense 
of  constriction  of  the  heart,  dyspnoea,  profound  shock,  and  cold  sweat 
are  characteristic.  A  whirring  sound  in  the  cardiac  region  occurs  in- 
frequently. Several  surgeons  have  in  common  discovered  a  symptom 
which  is  not  noted  by  some  others,  namely,  absence  of  radial  pulse  in 
the  left  wrist,  accompanied  by  a  weak  and  scarcely  palpable  pulse  in 
the  right  wrist  (Fischer,  Borzymowski,  Tscherniachowski).  Luxem- 
bourg lays  emphasis  on  the  feature  that  in  the  presence  of  heart  tam- 
ponade the  symptoms  of  air-hunger,  dyspnoea,  and  pain,  while  distress- 
ing when  the  patient  is  recumbent,  are  relieved  by  a  sitting  posture. 
Auscultation  and  percussion  invariably  reveal  an  enlargement  of  the 
heart  area,  which  is  further  demonstrated  by  the  radiograph.  If  this 
enlarged  heart  shadow  is  in  the  line  of  the  point  of  entrance  and  exit  of 
a  bullet,  or  coincides  with  that  area  toward  which  the  canal  of  entrance 
of  a  stab  wound  is  pointing,  further  evidence  of  hemopericardium  is 
furnished. 

As  hemopericardium  continues,  the  right  side  of  the  heart  is  com- 
pressed, the  blood  from  the  large  veins  ceases  to  enter  the  auricles,  the 
ventricles  are  soon  emptied  and  the  heart,  now  devoid  of  blood,  ceases 
to  beat. 

Although  this  condition  of  hemopericardium  may  usually  be  recog- 
nized and  may  even  be  verified  by  exploratory  puncture,  pleural  com- 


SURGERY    OF    THE   HEART,    PERICAROroM   AND    DIAPHRAGM         547 

plications  render  the  diagnosis  of  heart  injury  uncertain.  Flatness  at 
the  base  of  the  left  chest  with  symptoms  of  hemorrhage  indicate  hemo- 
thorax at  least.  This  accumulation  of  blood  may  come  from  the  lung 
or  from  the  pericardium,  or  from  both.  In  many  cases,  with  hemo- 
thorax there  exists  also  a  hemopneumo thorax.  If  the  injured  pul- 
monary vessels  alone  produce  the  hemorrhage,  the  neighboring  air- 
passages  are  at  the  same  time  opened.  A  wound  in  the  pleural  lateral 
aspect  of  the  pericardium  may  result  in  profuse  hemorrhage  from  the 
heart  into  the  pleural  cavity,  but  such  a  wound  is  impossible  without 
concurrent  laceration  of  that  portion  of  the  upper  lobe  of  the  lung  which 
borders  the  pericardial  region. 

An  extensive  accumulation  of  blood  in  the  left  pleural  cavity  ob- 
scures the  left  border  of  the  heart  dulness  and  may  also  displace  the 
heart  to  the  right,  so  that  percussion  and  radiography  may  give  the 
same  appearance  to  the  right  of  the  sternum  as  does  hemopericardium. 
Dyspnoea,  shock,  air-hunger,  and  signs  of  hemorrhage  may  all  be  present 
from  lung  injury  alone.  If  the  heart  is  transpleurally  injured,  hemo- 
pericardium does  not  exist  because  the  heart  blood  leaks  into  the  pleural 
cavity.  In  such  instances,  therefore,  we  lack  the  characteristic  symp- 
toms of  pericardial  tension,  which  stamp  the  diagnosis  of  heart  wound 
alone. 

Treatment.— It  may  be  said  that  expectant  treatment  is  indicated 
in  but  one  group  of  heart  wounds,  namely,  that  in  which  a  small  wound 
in  the  heart  muscle  is  occluded  by  clot  formation  in  the  pericardium 
before  the  fatal  results  of  heart  tamponade  ensue.  Close  observationt 
in  such  instances  reveals  probable  heart  injury  alone.  As  signs  and 
symptoms  develop,  there  may  be  indications  that  the  hemorrhage  is 
self  limited  by  the  pericardium.  Operation  occasionally  may  be 
needless  under  such  circumstances. 

With  this  one  exception,  in  which  expectant  treatment  may  be 
indicated,  an  operation  should  be  promptly  and  seriously  considered  in 
every  case  in  which  there  is  reason  to  believe  that  the  heart  is  wounded. 
Obviously  in  those  cases  inevitably  fatal  in  spite  of  all  we  can  do, 
operation  will  only  serve  to  raise  the  mortality  of  a  series  of  operations 
which  up  to  this  time  have  justified  their  being. 

Two  new  agents  are  now  at  our  disposal  in  operating  on  these  grave 
cases,  and  these  agents  should  increase  our  enthusiasm  to  operate, 
namely,  transfusion  and  intratracheal  insufflation  (or  else  dilTerential 
pressure).  Saline  infusions  have  in  the  past  been  administered  before 
and  during  reported  operations  for    heart   wounds   with    undoubted 


548  REGIONAL   SURGERY 

stimulative  effect.  Transfusion  at  the  moment  of  completing  the  heart 
suture  should  be  of  specific  value  to  restore  blood  pressure  and  to  provide 
the  heart  muscle  with  working  material. 

Inasmuch  as  pneumothorax  is  associated  with  at  least  seventy- 
five  per  cent,  of  heart  injuries,  collapse  of  the  lung  may  occur  either 
before  or  during  the  operation.  Writers  have  been  loath  to  credit  a 
death  from  operation  on  heart  wounds  to  the  effect  of  pneumothorax, 
either  previously  produced  or  resulting  from  the  thoracotomy,  for  in  the 
presence  of  profound  hemorrhage  and  manual  and  instrumental  trauma 
to  the  heart  muscle,  the  presence  of  air  in  the  pleural  cavity  seems  of 
secondary  importance  and  an  inadequate  excuse  for  the  death.  It 
cannot  be  denied,  however,  that  collapse  of  the  lung  alone  will  cause 
changes  in  the  pulmonary  circulation,  and  that  this  collapse  in  certain 
cases  markedly  and  even  fatally  restricts  the  respiratory  function  of  the 
remaining  lung.  Whether  this  factor  may  in  a  given  case  be  of  great  or 
partial  significance,  the  prevention  of  this  dangerous  collapse  is  certainly 
of  value. 

Intratracheal  insufflation,  now  an  established  method  of  main- 
taining a  complete  oxidation  of  the  blood  in  spite  of  restricted  res- 
piratory function,  should  be  employed  in  all  operations  for  heart  wound. 
If  the  apparatus  is  not  at  hand,  ether  under  the  pressure  of  an  oxygen 
tank  may,  by  resisting  expiration,  maintain  inflation  of  the  lung  and 
thus  improve  the  pulmonary  circulation. 

The  advantages  of  intratracheal  insufflation  (or  of  differential 
pressure)  at  these  operations  are  as  follows: 

1.  Economy  of  time.  With  the  employment  of  differential  pres- 
sure the  pleura  may  be  opened  widely.  There  is  no  loss  of  time  and 
effort  to  avoid  injury  to  the  pleura,  an  effort  usually  unsuccessfully 
attempted  in  the  extrapleural  methods. 

2.  All  anxiety  concerning  the  possible  fatal  effects  of  pneumothorax 
is  obviated. 

3.  Inflation  of  the  lung  discloses  the  injured  areas  in  the  lungs  by 
the  escape  of  air,  facilitating  their  localization  and  repair. 

4.  Differential  pressure,  by  maintaining  the  expansion  of  the 
lungs,  prevents  the  sagging  of  the  heart  posteriorly,  upward  and  to 
the  left. 

5.  The  reinflation  of  the  lung  at  the  end  of  operation,  followed 
by  tight  closure  of  the  intercostal  wound,  prevents  the  persistence  of 
pneumothorax  which  leads  to  infection,  the  usual  cause  of  death  in 
these  cases  which  survive  the  operation  itself. 


SURGERY    OF    THE   HEART,    PERICAROroM   AND   DIAPHRAGM         549 

Technique  of  Operation. — The  patient  should  be  in  the  dorsal 
position  with  a  low  sand  bag  partially  elevating  the  left  chest.  Pre- 
liminary ether  anaesthesia  is  started,  and  the  intratracheal  tube  is  then 
introduced.  During  this  interval  the  skin  is  prepared  with  benzine 
and  iodine. 

In  determining  the  preferable  method  of  approach  in  this  group 
of  cases,  an  attempt  should  be  made  to  determine  whether  the  pleura 
and  lung  also  are  involved.  The  point  and  angle  of  entrance  of  the 
bullet  or  knife  will  aid  in  this  determination.  If  there  be  symptoms  of 
heart  tamponade — namely,  hemopericardium,  with  iricreasing  tension, 
and  absence  of  signs  pointing  to  intrapleural  injury — an  extrapleural 
approach  through  the  precordial  space  is  indicated;  or  in  further  detail, 
given  a  diagnosis  of  heart  injury  alone,  a  skin  flap  may  be  reflected 
which  will  include  that  part  of  the  heart  area  designated  by  the  ex- 
ternal wounds.  The  wound  should  then  be  further  explored.  If 
injury  to  the  base  of  the  heart  is  suspected,  resection  of  portions  of 
the  sternum  may  be  required,  together  with  two,  three  or  more  costal 
cartilages.  For  this  approach  to  the  heart  via  the  anterior  mediastinum, 
at  least  twenty  different  skin  incisions  and  osteoplastic  operations 
have  been  employed.  The  sternum  may  be  bisected  and  partially  re- 
sected. Two,  three  and  four  ribs  may  be  divided  and  reflected  out- 
ward or  medianward,  or  resected  for  varying  lengths  with  and  without 
their  cartilaginous  portions.  Flaps  of  skin,  muscle,  bone  and  pleura 
may  be  reflected,  with  division  of  the  ribs  at  one  edge  of  the  flap  and 
fracture  at  the  hinge.  The  hinge  of  such  flaps  may  be  made  toward 
the  median  line  or  away  from  it.  The  incision  may  start  vertically 
over  the  sternum  and  extend  laterally  in  a  direction  parallel  to  the 
underlying  ribs.  The  cartilages  of  several  ribs  may  be  divided  and 
intercostal  incisions  may  be  made  above  and  below  the  upper  and 
lower  divided  ribs  respectively.  The  rib-and-intercostal-muscle  flap 
may  then  be  sprung  away,  exposing  a  window. 

Intercostal  Incision. — The  precordial  osteoplastic  exposures  men- 
tioned above  have  been  developed  in  consequence  of  the  reluctance 
hitherto  shown  by  surgeons  to  enter  the  pleural  cavity.  Experimental 
chest  surgery  has  demonstrated  the  usefulness  and  safety  of  wide  open 
thoracic  intercostal  exposures  for  approach  to  the  heart,  lung,  oesophagus 
and  diaphragm.  The  long  lateral  intercostal  incision  extending  from 
the  sternum  across  the  axilla  with  separation  by  the  use  of  a  strong 
rib-spreader,  was  recommended  by  Mikulicz,  and  was  successfully 
developed    by    Sauerbruch.     Its    advantages    in    heart    injuries    are 


550  REGIONAL   SURGERY 

several.  The  lung  may  be  carefully  explored  for  accompanying  wounds. 
The  heart  and  pericardium  may  be  freely  exposed.  This  chest  open- 
ing is  ample  to  permit  of  manual  compression  of  the  great  vessels. 
Pericostal  silk  stitches  will  closely  approximate  the  ribs  at  the  end  of 
the  operation  and  thus  prevent  post-operative  pneumothorax,  and 
unusual  complication  in  these  cases. 

There  is  reason  to  believe  that  the  ultimate  technique  for  this  group 
of  injuries,  involving  either  the  heart  or  lung  or  both,  will  be  the 
employment  under  differential  pressure  of  this  long  intercostal  in- 
cision, with  spreading  of  the  ribs  and  exposure  of  both  the  areas  in 
question. 

When  the  heart  area  has  been  exposed  by  one  of  the  above-men- 
tioned methods,  although  the  pleural  cavity  may  contain  blood,  and 
bleeding  wounds  of  the  lung  be  discovered,  the  pericardium  should  be 
carefully  examined  and  the  possibility  of  heart  wound  not  forgotten, 
even  in  the  absence  of  lacerations  of  the  pericardium.  Fourteen  cases 
are  now  recorded  of  rupture  of  the  heart  muscle  in  the  presence  of  an 
intact  pericardium.  Wilms  explains  this  at  first  incomprehensible 
condition  on  the  principles  of  hydrodynamics.  It  occurs  presumably 
only  in  cases  of  bullet  injuries.  The  elasticity  of  the  pericardium 
may  allow  the  bullet  to  administer  a  sudden  blow  upon  the  more 
resistant  contracted  heart  muscle,  which  produces  a  rupture  rather 
than  a  perforation  of  the  ventricular  wall.  Luxembourg  reports  a 
case  in  which  two  bullets  were  found  lying  in  the  anterior  mediastinum 
without  perforation  of  the  pericardium.  Both  bullets  were  removed 
and  the  operation  abandoned.  Death  ensued,  and  autopsy  revealed 
a  double  heart  wound  which  resulted  in  hemopericardium  and  death. 
It  would  seem,  therefore,  that  in  all  cases  of  this  group  of  chest  injuries 
the  pericardium  should  he  incised  if  there  is  any  accumulation  of  blood 
within  it,  lest  one  of  these  hidden  heart  ruptures  he  overlooked. 

It  is  at  the  moment  of  the  pericardiotomy  that  the  critical  moment 
of  these  operations  sometimes  presents.  All  resistance  to  heart 
leakage  which  the  pericardium  may  have  hitherto  provided  is  sud- 
denly removed.  Sometimes  the  hole  in  the  ventricle  may  be  small 
and  the  hemorrhage  slight.  In  some  cases  the  immediate  blood  loss 
is  terrific.  If  violent  hemorrhage  exists,  an  attempt  to  check  it  is  of 
primary  importance  before  attempting  the  suture.  Loss  of  blood  prev- 
ious to  this  moment  may  also  have  been  of  great  consequence.  If  the 
wound  is  in  plain  view,  the  stream  spurting  from  a  ventricle  strikes 
face  and  eyes  of  the  operator  with  surprising  accuracy.     One  stitch. 


SURGERY   OF    THE   HEART,    PERICARDIUM   AND   DL\PHRAGM         55 1 

when  introduced  and  tied,  is  seldom  enough  to  check  the  flow.  Ten- 
sion on  the  first  stitch  with  the  hope  of  checking  hemorrhage  is  likely 
to  result  in  tearing  the  heart  muscle.  Tension  which  may  be  endured 
by  the  muscle  at  diastole  is  suddenly  increased  at  systole  with  a  result- 
ing tear.  The  trauma  to  the  heart  muscle  causes  immediate  in- 
creased rapidity  of  contraction,  and  the  introduction  of  sutures  under 
these  conditions  of  violent  motion  and  hemorrhage  is  quite  impossible. 

Rehn,  Haecker,  Tigerstedt,  Noetzel,  Lawen  and  Sievers,  and 
Elsberg  have  determined  the  length  of  time  which  animals  will  endure 
the  compression  of  the  great  vessels  at  the  base  of  the  heart.  Lawen 
and  Sievers  conclude  that  in  closure  of  the  vena  cava  the  lung  and 
coronary  circulations  remain  intact  for  nine  minutes  in  the  rabbit, 
although  distinct  disturbances  from  cerebral  anaemia  are  noted  in  the 
interim.  For  three  minutes  the  veins  may  be  compressed  without 
disturbances  of  either  heart  or  brain.  They  state  further  that  compli- 
cations can  be  lessened  if  the  compression  is  remitted  from  time  to 
time,  even  at  the  expense  of  a  sHght  loss  of  blood.  Sauerbruch  con- 
cludes from  experiments  that  the  superior  and  inferior  cavae  may  be 
compressed  for  ten  minutes,  during  which  time  the  heart-beat  is  small 
and  irregular.  On  removing  the  compression,  the  right  ventricle  be- 
comes suddenly  dilated,  and  the  heart-beat  momentarily  ceases.  A 
more  extensive  series  of  experiments  by  Haecker  results  in  similar 
conclusions. 

The  writer  has  employed  manual  compression  of  the  vessels  at 
the  base  during  repair  of  a  bullet  wound  of  the  left  ventricle.  The 
heart  suture  was  materially  facihtated  by  the  resulting  hemostasis. 
One  minute's  compression  upset  the  heart  action,  which  was  promptly 
restored  when  the  pressure  was  omitted. 

Experimental  investigation,  therefore,  and  a  limited  number  of 
reported  cHnical  attempts  emphasize  the  advisability  of  intermittent 
vessel  compressions  during  suture  of  heart  wounds. 

Looking  further  for  means  of  hemostasis  during  heart  suture, 
when  hemorrhage  is  profuse,  we  find  possibilities  in  the  use  of  dif- 
ferential pressure.  Sauerbruch,  using  negative  pressure  in  experimental 
suture  of  artificial  heart  wounds,  has  noted  that  allowing  the  lung  to 
collapse  within  safe  limits  has  resulted  in  a  slowing  of  the  heart-beat 
and  a  concurrent  diminution  in  the  hemorrhage  from  the  heart  wound. 
He  explains  this  phenomenon  on  the  basis  that  the  collapsed  lung  re- 
tains more  blood  than  is  normal  to  it,  and  that  resultingly  less  blood 
for  the  time  enters  the  heart.     The  slowing  of  the  heart-beat,  together 


552  REGIONAL   SURGERY 

with  slight  dyspncea,  is  a  well-known  symptom  of  the  effects  of  pneu- 
mothorax and  lung  collapse,  and  many  observers  have  been  impressed 
with  the  control  of  the  pulse-rate  by  raising  or  lowering  the  differential 
pressure. 

As  regards  the  technique  of  the  suture  itself,  death  has  seldom  oc- 
curred from  subsequent  leakage  if  the  suture  is  once  estabhshed;  in 
fact  one  might  even  conclude  that  the  kind  of  material  is  of  com- 
paratively little  significance.  Round  needles  and  interrupted  sutures, 
not  including  the  endocardium,  are  to  be  preferred. 

Drainage. — Of  112  cases  of  stab  and  bullet  wounds  of  the  heart 
which  survived  the  operation  itself,  76  (60  per  cent.)  had  infections 
of  the  pericardium  or  pleura  or  both.  Forty-one  of  these  died  and 
26  recovered  (Peck).  A  study  of  the  individual  infected  cases 
shows  that  infection  occurred  a  trifle  more  frequently  with  drainage 
than  without.  Rehn  and  Vaughan  accept  these  statistics  as  evidence 
that  drainage  is  not  advisable  except  in  cases  where  hemostasis  has 
not  been  complete. 

Drainage  of  the  pleural  cavity  should  not  be  estabhshed  at  the 
end  of  operation  for  two  reasons : 

First.  If  a  virulent  infection  has  been  introduced  at  the  time 
of  injury  or  operation,  the  introduction  of  a  drain  to  the  pleural  cavity 
will  be  insufficient  to  check  the  progress  of  an  acute  septicaemia.  If, 
on  the  other  hand,  the  infection  is  less  virulent  and  confined  to  the 
pleura,  there  is  probably  no  danger  in  waiting  until  the  symptoms  of 
empyema  develop.  Adhesions,  too,  may  have  occurred  in  the  interim 
which  will  tend  to  locaHze  the  septic  process.  Drainage  may  then 
be  estabhshed  with  a  suction  method,  which  will  dispose  of  the  infectious 
material  without  permitting  complete  lung  collapse. 

Second.  It  is  a  weU-recognized  fact  that  the  presence  of  pneu- 
mothorax favors  infection  after  operation.  The  presence  of  drainage 
at  once  estabHshes  this  infection. 

In  this  connection  it  should  be  remembered  that  it  is  quite  as 
important  to  obliterate  the  pleural  space  before  closure  as  it  is  to 
omit  drainage.  If  obliteration  is  neglected  and  the  lung  is  left  in  the 
collapsed  state,  atmospheric  pressure  persists  in  one  pleural  cavity 
while  the  normal  negative  pressure  remains  in  the  unopened  side  of 
the  thorax.  The  resulting  inequahty  in  the  pressure  of  the  two  sides 
of  the  chest  prevents  the  reexpansion  of  the  collapsed  lung,  and  often 
causes  a  pleuritic  transudate  which  serves  as  an  admirable  culture 
medium.     To  prevent  this,  normal  negative  pressure  in  the  wounded 


SURGERY   OF   THE   HEART,    PERICARDIUM   AND   DIAPHRAGM         553 

side  should  be  restored,  either  by  artificial  inflation  just  before  the 
tying  of  the  last  wall  suture,  or  by  aspiration  after  the  closure  of  the 
wound.  If  differential  pressure  is  at  hand,  the  artificial  inflation  is 
employed  without  difficulty.  • 

The  resistance  of  the  patient,  not  only  to  infection  but  to  the 
blood  loss  and  shock,  is  undoubtedly  increased  by  the  restored  function 
of  the  collapsed  lung.  The  balance  between  the  pulmonary  and  aortic 
circulation  is  restored  to  normal,  and  the  oxygenating  lung  surface  is 
not  reduced  at  this  time  of  need. 

Concerning  drainage  of  the  pericardium,  the  consensus  of  opinion  is 
in  favor  of  closure  with  subsequent  aspiration  if  pericarditis  ensues. 

Closure  of  the  thoracic  wall  wound  is  simple  when  an  intercostal 
Sauerbruch  incision  has  been  made.  Interrupted  braided  silk  sutures 
should  be  used,  encircling  the  two  ribs  above  and  below  the  incised 
intercostal  space.  All  available  muscle  tissue  should  then  be  approxi- 
mated with  interrupted  chromicized  catgut.  The  artificial  lung  infla- 
tion should  be  maintained  at  least  up  to  the  completion  of  the  muscle 
stitching.     The  skin  is  closed  with  a  continuous  silk  suture. 

Closing  the  osteoplastic  flap  wounds  is  more  difficult.  Air  leakage 
is  common.  Great  care  should  be  exercised  in  utilizing  muscle  and 
fascia  to  seal  the  spaces  between  rib  ends,  sternal  edges  and  cartilage 
fragments. 

Cardiolysis. — {An  operation  for  the  treatment  of  adhesive  mediastino- 
pericarditis) . — Cardiolysis  has  been  attended  with  sufficient  success  in 
ten  years  to  justify  its  continuance.  The  operation  is  not  intended  for 
the  relief  of  the  common  single  adhesive  pericarditis  in  which  the  layers 
of  the  pericardium  are  adherent  to  each  other.  It  is  applicable  only  to 
the  pericarditis,  characterized  by  the  existence  of  adhesions  between 
the  pericardium,  pleura,  diaphragm  and  mediastinum  and  a  general 
glueing  together  of  the  adjacent  serous  surfaces  in  the  lower  median 
segment  of  the  thoracic  cavity.  Cardiolysis,  furthermore,  should  not 
be  confounded  with  Delorme's  unpromising  operation,  the  object  of 
which  is  to  separate  these  adhesions.  Cardiolysis  is  an  extrathoracic 
operation  upon  the  chest  wall  in  which  ribs  are  resected  from  the  peri- 
cardial region  for  the  sole  purpose  of  converting  a  bony  resistant 
portion  of  the  thoracic  cage  into  a  yielding  flexible  diaphragm. 

The  chief  sign  of  adhesive  mediastinal  pericarditis  is  a  perceptible 
rhythmic  retraction  of  the  intercostal  spaces  over  the  cardiac  area, 
this  retraction  occurring  during  the  heart  systole.  The  systolic  re- 
traction is  followed  by  a  diastolic  bulging.     On  the  supposition  that 


554  REGIONAL    SURGERY 

this  symptom  indicates  an  effort  on  the  part  of  the  heart  to  obtain  more 
flexibihty  of  motion,  Rudolph  Brauer  suggested  this  cariolysis  to  force 
the  chest  wall  to  yield  to  the  heart's  persistent  tugging.  Other  symp- 
toms and  signs  of  the  disease  are  diastolic  collapse  of  the  jugular  veins, 
pulsus  paradoxus,  myocarditis,  enlargement  of  the  liver  and  ascites, 
all  of  these  being  associated  with  a  restricted  return  of  the  venous  blood 
to  the  right  heart,  accompanied  by  a  weakening  of  the  heart  muscle  in 
its  effort  to  compensate  for  mechanical  obstruction. 

Many,  and  sometimes  all,  of  these  symptoms  have  been  relieved  by 
the  operation  of  cardiolysis. 

Technique  of  Operation. — A  curved  incision  is  made  with  its  con- 
vexity downward  and  at  the  level  of  the  fourth  rib  extending  from  the 
left  sternal  border  to  the  anterior  axillary  line.  A  skin  and  muscle  flap 
thus  produced  is  reflected  upward  exposing  the  third,  fourth  and  fifth 
ribs  from  the  costochrondal  junction  for  a  distance  outward  of  8  to  9 
cm.  These  three  ribs  are  then  resected  subperiosteally.  A  difference 
of  opinion  exists  regarding  the  advisability  of  removing  the  periosteum 
also.  Its  removal  greatly  increases  the  risk  of  tearing  the  parietal 
pleura,  an  accident  which  produces  complications  that  may  convert  an 
otherwise  safe  procedure  into  a  fatal  one.  Not  that  the  resulting  pneu- 
mothorax will  instantly  endanger  life,  but  rather  that  the  existence  of 
pneumothorax  generally  leads  to  an  effusion  which  in  such  cases  readily 
becomes  infected.  For  many  months  the  subperiosteal  resection  pro- 
vides the  desired  flexible  area  in  the  chest  wall.  All  the  relief  to  be 
expected  will  occur  during  this  period  to  the  same  degree  as  when  the 
periosteum  also  is  removed.  If  the  periosteum  is  left  and  re-formation 
of  the  bone  or  cartilage  follows,  the  original  purpose  of  the  operation 
is  destroyed.  This  re-formation  of  bone  is  a  certain  disadvantage. 
On  the  other  hand,  the  extensive  removal  of  periosteum  may  involve 
injury  to  the  pleura,  and  no  surgeon  should  attempt  removal  of  the 
periosteum  until  he  has  previously  performed,  in  a  few  cases  at  least, 
the  operation  by  the  subperiosteal  resection  method. 

Variations  in  the  above  technique  have  been  recommended,  includ- 
ing the  removal  of  costal  cartilages  and  a  portion  of  the  sternum. 
It  is  doubtful  if  any  further  benefit  is  accomplished  by  so  doing  and  here 
again  pleural  laceration  is  imminent.  Certain  enthusiasts  recommend 
cardiolysis  even  when  its  leading  sign,  systolic  retraction  of  the  inter- 
costal spaces,  is  absent.     I  question  such  conclusions. 

Pericardial  Effusions. — Accumulations  of  fluid  in  the  pericardium 
are  often  associated  with  other  serous  exudates,  especially  those  of  the 


SURGERY    OF   THE    HEART,    PERICARDIUM   AND   DIAPHRAGM         555 

pleura.  These  effusions  are  often  tuberculous.  Embarrassed  heart  ac- 
tion is  essentially  an  indication  for  the  removal  of  the  fluid.  Simple 
aspiration  is  sometimes  sufficient  for  temporary  relief.  The  needle 
should  be  introduced  in  the  fourth  left  interspace  i)^  in.  from  the  left 
sternal  border.  Injury  to  the  pleura  is  generally  avoided  because  of 
the  distended  pericardium. 

Hemorrhagic  and  purulent  exudates  are  seldom  relieved  by  aspira- 
tion. In  such  cases  the  fourth  or  fifth  costal  cartilage  should  be 
carefully  excised,  and  an  incision  made  to  the  pericardial  sac,  with  evacu- 
ation of  clots  or  pus,  followed  by  drainage. 

Diaphragm. — Surgery  of  the  diaphragm  is  confined  essentially  to 
the  repair  of  diaphragmatic  herniae,  to  the  excisions  of  tumors  involving 
the  diaphragm,  and  to  the  transpleural  approach  to  subdiaphragmatic 
viscera.  As  to  the  technique  of  such  operations,  certain  general  con- 
siderations may  be  mentioned,  the  details  being  determined  by  the 
nature,  location  and  extent  of  the  given  lesion. 

Intratracheal  insufflation,  or  the  use,  if  we  choose,  of  differential 
pressure,  should  be  instituted  in  all  such  cases.  A  long  intercostal 
incision  lying  just  above  the  diaphragmatic  level  should  be  employed, 
extending  from  the  sternal  border  to  the  posterior  axillary  line.  A  rib- 
spreader  is  used.  If  the  purpose  of  the  operation  cannot  be  accom- 
plished through  the  pleural  cavity,  a  subordinate  high  abdominal  in- 
cision should  be  made,  thus  permitting  access  to  the  diaphragmatic 
lesion  both  from  above  and  below. 


THE  BREAST 

SECTION  XXIII 
LESIONS  OF  THE  FEMALE  BREAST 

By 

JOSEPH   COLT  BLOODGOOD,  B.  SC,   M.  D.,  F.   A.   C.   S. 

Baltimore,  Md. 

Attention  is  called  to  the  female  breast  by  swelling,  or  tumor, 
pain,  discharge  from  or  retraction  or  ulceration  of,  the  nipple;  some 
change  in  an  area  of  skin  over  the  breast,  or  the  palpation  of  some 
enlargement  of  the  glands  in  the  axilla. 

When  the  patient  seeks  advice  for  one  or  more  of  these  signs  and 
symptoms,  we  may  be  somewhat  influenced  and  helped  in  our  in- 
terpretation of  their  significance  by  the  following  additional  data :  age, 
duration  of  symptoms;  whether  the  symptoms  had  disappeared  to 
reappear — especially  tumor;  whether  the  woman  is  married  or  single, 
whether  pregnant  or  nursing  her  child,  the  number  of  children  and 
the  age  of  the  youngest;  whether  there  has  been  a  history  of  trauma 
or  mastitis;  whether  the  menstruation  is  normal,  changing,  or  the 
menopause  established.  The  existence  of  pelvic  irritating  lesions 
should  also  be  carefully  investigated. 

Breast  Lesions. — We  may  have  at  birth,  puberty  and  during 
pregnancy  a  diffuse  enlargement  of  both  breasts — a  condition  which 
can  always  be  recognized  clinically  and  should  never  be  confused 
with  a  malignant  tumor. 

Mastitis  as  a  rule  is  associated  with  lactation.  It  is  always  a 
diffuse  lesion,  never  encapsulated,  but  may  be  circumscribed.  We 
do  observe  mastitis  in  breasts  which  are  not  lactating.  Then  the 
mastitis  is  usually  tubercular. 

We  do  not  know  the  etiology  of  chronic  cystic  mastitis.  The 
affected  area  is  never  encapsulated  but  the  large  cysts  which  develop 
in  a  large  per  cent,  of  cases  are  individually  encapsulated.  The 
disease  may,  however,  appear  as  a  circumscribed  tumor. 

Cysts   of   the   breast   are  galactoceles   associated   with  lactation; 

557 
Copyright,  191 7,  by  P.  Blakiston's  Son  &  Co. 


558  REGIONAL   SURGERY 

pyogenic  and  tuberculous  abscesses;  cysts  in  chronic  cystic  mastitis; 
papillomatous  cysts,  benign  and  malignant;  and  the  true  cancerous 
and  sarcomatous  cyst. 

Encapsulated  tumors  are  always  benign.  They  are  the  cystic 
adenoma,  the  fibroadenoma  and  the  intracanalicular  myxoma.  These 
tumors,  however,  may  appear  as  circumscribed  areas  difl&cult  to 
differentiate  from  adenocarcinoma. 

Malignant  tumors  are  never  encapsulated,  although  they  may 
be  circumscribed.  The  types  of  malignant  tumors  are  the  adeno- 
carcinoma, the  scirrhous  and  medullary  carcinoma,  and  the  sarcoma. 

We  must  recollect  that  cancer  may  begin  in  the  breast  during 
pregnancy,  during  lactation,  and  at  any  period  of  life  after  twenty-five. 

Cancer  may  form  in  the  scar  residual  after  mastitis  in  which  the 
original  lump  had  remained  quiescent  for  from  10  to  30  years. 

Tumors  may  remain  quiescent  in  the  breast  for  many  years.  When 
growth  suddenly  appears,  it  is  usually,  but  not  always,  associated 
with  malignant  change. 

To  increase  the  number  of  cures  of  cancer  of  the  breast,  we  must 
give  women  the  proper  information  which  will  influence  them  to  seek 
an  examination  the  moment  after  they  feel  a  lump. 

The  most  difficult  problem  falls  upon  the  surgeon — to  differentiate 
at  the  exploratory  incision  the  various  types  of  breast  lesions  and  to 
decide  then;  whether  to  remove  the  lump,  the  breast,  or  to  perform 
the  complete  operation  for  sarcoma  or  carcinoma. 

Age.— Among  885  malignant  tumors  of  the  breast  thirty-five  or 
3.9  per  cent,  have  been  under  thirty  years  of  age  when  the  lump  was 
first  observed.  In  10  cases  the  age  of  onset  varied  from  15  to 
25  years.  In  six  cases  of  cancer  in  which  the  age  of  onset  was 
less  than  twenty-five,  the  tumors  had  been  observed  from  5  to  40 
years,  thus  offering  ample  time  for  removal  during  the  benign  stage. 

There  remains  but  one  positive  case  of  cancer  originating  in  a 
woman  younger  than  twenty-five.  This  patient  was  21  years  of  age 
and  had  observed  the  lump  but  a  few  months. 

Of  the  four  cases  of  sarcoma  in  which  the  patients  were  younger 
than  twenty-five  when  the  neoplasms  were  first  discovered,  in  two  the 
tumors  were  of  18  and  25  years'  duration  respectively.  The  remain- 
ing two  cases  are  from  outside  sources,  and  I  have  been  unable  to 
confirm  the  data. 

Therefore,  when  a  patient  with  a  lump  in  the  breast  is  twenty- 
five  or  less,  the  chances  of  a  malignant  tumor  are  remote.     After 


LESIONS    OF   THE   FEMALE   BREAST  559 

twenty-five  age  does  not  help  us,  because  cancer  has  been  observed 
from  twenty-six  to  seventy  and  over,  as  well  as  all  types  of  benign 
tumors. 

In  the  newborn  we  may  observe  enlargement  of  the  breast;  this  is 
usually,  if  not  always,  bilateral,  and  associated  with  a  discharge  milky 
in  character  {infantile  hypertrophy).  This  condition  recovers  spon- 
taneously. On  account  of  the  discharge  from  the  nipple,  efforts  to 
attain  and  maintain  cleanliness  should  be  great.  After  washing,  the 
nipple  should  be  protected  with  sterile  cotton.  Infections  have  taken 
place;  abscesses  and  erysipelas  have  secondarily  developed  with 
mortality.  My  one  observation  recovered,  and  now,  17  years  since, 
the  breast  has  normally  developed. 

During  childhood  diseases  of  the  breast  are  unusual  and  always 
benign.  Tumors  need  not  be  removed  unless  they  grow,  or  are  asso- 
ciated with  great  pain. 

At  puberty  benign  conditions  of  the  breast  are  often  first  observed. 
The  attitude  towards  all  lesions  at  this  period  should  be  conservative. 
Intense  pain,  rapidly  growing  tumor,  huge  enlargement  of  one  or  both 
breasts,  are  the  only  indications  for  operative  interference.  The 
object  of  such  an  operation  is  not  to  cure  any  hopeless  disease,  but  to 
check  and  remove  a  lesion  which,  if  left  alone,  would  destroy  the  breast, 
or  to  relieve  pain  by  the  removal  of  a  centrally  situated  tumor. 

Unilateral  Hypertrophy. — At,  or  shortly  after,  puberty  the  de- 
velopment of  one  breast  may  be  more  rapid  than  of  the  other.  In 
six  cases  of  my  own  observation  the  larger  breast  was  not  suflSciently 
large  to  excite  any  apprehension.  The  condition  was  really  not 
unilateral  hypertrophy,  but  unilateral  development.  In  these  six 
cases  after  a  time  the  more  slowly  developing  breast  caught  up  with  the 
other  and  symmetry  was  established.  In  one  case  the  hypertrophy 
of  the  left  breast  was  far  out  of  proportion  to  normal,  while  the  smaller 
breast  was  about  normal  for  a  girl  two  years  after  puberty.  In  this 
case,  with  the  hope  of  checking  the  hypertrophy,  a  plastic  resection  of 
a  quadrant  was  performed.  It  is  now  about  10  months  since  the 
operation,  and  there  has  been  no  further  enlargement.  We  know  from 
our  experience  with  operations  for  benign  tumors  of  the  breast  during 
and  after  puberty  that  there  is  no  harm  from  such  a  plastic  resection, 
but  we  have  no  evidence  as  yet  that  it  will  check  unilateral  hypertrophy. 

Diffuse  Bilateral  Virginal  Hypertrophy. — This  condition  has 
its  onset  at,  or  shortly  after,  puberty.  At  first  there  is  observed 
the  ordinary  puberty  hypertrophy.    Later  both  breasts   become   so 


56o 


REGIONAL   SURGERY 


much  larger  than  normal  that  interest  and  anxiety  are  excited.  In 
the  literature  the  cases  are  usually  observed  from  four  to  ten  years 
after  onset,  and  nothing  has  been  done  for  this  condition,  except  re- 
moval of  one  or  both  breasts.  Apparently  in  this  late  stage  nothing 
else  offers  any  relief.  If  these  cases  are  seen  in  the  beginning  of  the 
trouble,  menstrual  disorders  should  be  corrected,  sexual  disturbances 
controlled,  and  when  the  size  of  the  breast  has  gone  much  beyond 
normal,  plastic  resection  as  noted  above  might  be  attempted. 

Now  and  then  unilateral  hypertrophy  may  be  due  to  the  presence 
of  a  tumor  in  the  center  of  the  breast.     In  my  only  observation  in- 


FiG.  301. — Encapsulated  aberrant  fibroadenoma.     Tumor    larger    than    the     breast. 

Breast  to  the  median  side. 

Pathol.   No.    7135. — Operation  in   1906,  excision  of  tumor;  breast  saved.     Colored, 

female,  aged  19,  tumor  seven  months 

tense  pain  was  the  indication  for  operation.  At  the  exploratory  in- 
cision previous  to  the  contemplated  plastic  resection,  the  central 
tumor  was  found  and  removed.  The  pain  was  relieved,  and  10  years 
later  this  breast  lactated  normally. 

At,  or  shortly  after,  puberty  tumors  in  the  region  of  the  breast 
may  develop,  grow  rapidly  and,  if  left  alone,  become  larger  than  the 
breast  itself  (Fig.  301).  They  are  usually  incorrectly  diagnosed  sarcoma, 
and  the  young  patients  are  mutilated  for  life  by  the  removal  of  a  nor- 
mal breast  with  a  benign  encapsulated  tumor.  These  are  aberrant  breast 
tumors,  and  will  be  discussed  again  under  fibroadenoma  (page  598). 

At  what  age  should  a  single  tumor  of  the  female  breast  be  removed? 


LESIONS    OF   THE    FEMALE   BREAST  56 1 

In  my  own  opinion,  if  the  patient  is  under  twenty,  the  tumor  may  be 
left  alone,  unless  it  exhibits  growth,  or  is  very  annoying  by  pain. 
Between  twenty  and  twenty-live  there  is  some  doubt  as  to  what  is 
best  to  do.  On  the  whole,  accumulated  experience  favors  operation. 
After  twenty-five  there  is  no  question — operate. 

In  many  of  the  single  and  multiple  tumors  in  girls  under  twenty- 
five  which  I  have  observed  during  the  past  25  years  the  tumors 
have  spontaneously  disappeared.  Young  girls,  if  possible,  should 
not  be  subjected  during  puberty  to  operations  upon  the  breast. 
After  twenty  the  chances  of  spontaneous  disappearance  grow  less,  and 
as  the  tumor  certainly  should  be  removed,  if  it  does  not  disappear  in  a 
few  years,  why  wait?  There  is  no  danger  and  no  mutilation.  The 
removal  of  these  benign  tumors  protects  the  woman  from  growth 
of  this  tumor  which  may  take  place  during  a  subsequent  pregnancy 
or  lactation  at  a  time  when  an  operation,  even  for  a  benign  tumor, 
is  more  annoying  than  at  an  earlier  period.  There  is  also  no  doubt 
that  it  protects  the  woman  from  the  possible  development  of  a  cancer 
in  such  a  benign  tumor,  v  w&i* 

In  women  after  25  years,  their  age  can  no  longer  be  used 
as  a  factor  either  against  operative  interference,  or  in  differential 
diagnosis.  Although  the  relative  proportion  of  benign  and  malignant 
diseases  of  the  breast  varies  with  the  age  of  the  patient,  it  is  not  suf- 
ficiently distinct  to  be  helpful.  If  a  surgeon  uses  age  in  his  differential 
diagnosis  after  twenty-five,  it  will  simply  increase  the  number  of  his 
mistakes. 

Duration  of  Tumor. — Theoretically,  our  patients  should  always 
see  us  at  once,  so  that  we  would  never  be  assisted  in  our  differential 
diagnosis  by  the  duration  of  the  disease.  When  the  woman  waits, 
always  at  her  own  risk,  the  surgeon  may  be  helped  by  the  long  duration 
of  the  disease  without  any  definite  change.  But  even  here,  there  are 
too  many  exceptions  to  the  rule,  to  allow  one  to  rely  much  on  the 
long  duration  of  the  disease.  Our  records  show  many  cases  of  cancer 
in  tumors  which  have  been  present  30  or  more  years.  We  know 
that  when  we  operated  the  tumors  were  cancer.  Our  records  may 
show  when  the  clinical  signs  of  cancer  first  developed,  but  we  have  no 
way  of  finding  out  when  or  why  the  malignant  change  took  place.  A 
tumor,  then,  of  many  years'  duration  which  during  this  time  has 
shown  no  growth  and  is  quiescent  today,  may  begin  its  malignant 
change  tomorrow. 

36 


562  REGIONAL   SURGERY 

When  the  duration  of  the  S3anptoms  is  helpful  in  the  differential 
diagnosis,  I  will  mention  it  later  with  the  specific  lesion  under  discussion. 

The  relative  per  cent,  of  benign  and  malignant  lesions  of  the  breast 
in  our  1800  cases  has  changed  gradually  in  the  past  27  years,  and 
very  rapidly  in  the  past  three  years.  In  the  first  10  years  of  the 
observation  the  per  cent,  of  benign  lesions  was  32,  in  the  second  period 
of  10  years  it  was  41,  in  the  next  seven  years  it  was  54,  but  in  the  past 
three  years  59  as  compared  with  47  in  the  preceding  three  years.  This 
increasing  proportion  of  the  benign  lesions  of  the  breast  has  been  asso- 
ciated with  a  shortening  of  the  duration  of  the  disease,  and  the  latter 
has  been  due  to  the  education  of  the  profession  and  the  public.  Any 
clinic  reporting  today  a  larger  per  cent,  of  cancers  of  the  breast  sug- 
gests that  this  clinic  is  getting  late  cases. 

The  greatest  changes  which  we  have  observed  in  the  past  few 
years  in  diseases  of  the  breast  are  the  duration  of  the  disease,  and  its 
pathology. 

ETIOLOGICAL  FACTORS 

Trauma. — Many  breasts  are  bruised  and  after  the  contusion 
there  may  be  ecchymosis  and  even  palpable  induration.  All  of  these 
signs  may  disappear  and  nothing  develop  later.  There  are  apparently 
but  few  records  of  such  cases.  I  now  have  three  which  have  been 
followed  from  the  onset  of  the  injury.  In  the  oldest  case  it  is  three 
years  since  the  trauma.  This,  like  many  other  conditions  of  the 
breast,  may  be  frequent,  but  we  know  little  about  it,  because  those 
who  keep  records  are  not  consulted. 

On  the  other  hand,  the  number  of  breast  lesions  secondary  to 
trauma  is  relatively  small,  but  sufficiently  large  to  impress  one  that 
trauma  must  be  considered  an  etiological  factor.  All  the  cysts  of  the 
breast  which  I  have  seen  in  young  women  under  twenty-five  have 
followed  a  trauma.  In  sarcoma  of  the  breast  trauma  is  a  much  more 
frequent  etiological  factor  than  in  carcinoma.  Trauma  may  excite 
the  growth  of  a  pre-existing  tumor,  and  this  subsequent  growth  may 
be  either  benign  or  malignant.  The  history  of  a  trauma,  either 
positive  or  negative,  is  of  no  help  in  the  differential  diagnosis. 

Breasts,  however,  which  have  been  injured  should  be  carefully 
watched.  If  the  induration  which  immediately  followed  the  con- 
tusion does  not  disappear  in  a  few  weeks,  the  area  should  be  explored. 
If  an  area  of  induration  or  a  tumor  appears  some  days  or  weeks  after 


LESIONS    OF   THE    FEMALE  BREAST  563 

the  trauma,  in  cases  in  which  nothing  was  present  immediately  after 
the  trauma,  exploratory  operation  is  indicated  at  once. 

Infection.^ — In  the  absence  of  pregnancy  and  lactation,  the  breast 
is  especially  immune  to  metastatic  involvement  in  general  or  local 
infection,  yet  this  may  occur,  as  will  be  discussed  under  mastitis. 
When  we  have  a  local  infection  on  the  body  or  on  the  upper  extremity, 
the  breast  now  and  then  is  secondarily  involved.  When  the  patient 
gives  a  history  of  tuberculous  glands  of  the  neck  which  have  healed; 
when  scars  from  a  recent  suppuration  in  the  axilla  are  seen;  when  sinuses 
are  found,  and  there  has  occurred  a  more  recent  enlargement  of  the 
breast,  the  chances  are  that  we  are  deahng  with  tuberculosis.  With- 
out such  a  history  such  a  breast  with  its  present  induration  and  re- 
tracted nipple  would  have  to  be  considered  the  seat  of  a  malignant 
lesion. 

The  history,  or  demonstration,  of  a  portal  of  infection  near  the 
infected  breast  may  now  and  then  urge  the  surgeon  to  explore  rather 
than  to  perform  the  complete  cancer  operation  for  a  breast  condition 
which  is  cHnically  malignant.  But  these  are  unusual  conditions  and 
can  only  be  fully  considered  in  a  monograph  or  case  reports. 

Pregnancy. — If  a  lump  is  felt  in  the  breast  of  a  pregnant  woman 
and  the  patient  is  over  twenty-five,  it  should  be  explored  at  once; 
during  pregnancy  as  well  as  in  the  lactation,  cancer  disseminates  with 
greater  rapidity.  At  exploration,  a  benign  tumor  may  be  exposed 
(Fig.  307).  All  lesions  of  the  breast  during  pregnancy  are  unusual. 
Benign  and  malignant  tumors  are  about  equally  di\'ided.  Among  the 
cancers  in  our  records  there  is  one  blood-cyst  and  no  sarcoma.  Among 
the  benign  lesions  tumors  predominate.  Mastitis  is  very  rare  and 
when  present  is  usually  tuberculous. 

When  a  woman  knows  that  she  had  the  lump  in  her  breast  before 
she  was  pregnant,  immediate  operation  is  not  so  essential,  but  it  is 
far  better  to  remove  the  lump  before  the  birth  of  the  child.  I  have 
usually  selected  the  period  between  the  third  and  the  fifth  month. 
The  tumor  should  be  removed,  because  during  lactation  it  is  more 
apt  to  give  trouble.  It  seems  safer  for  the  child  to  remove  the  breast 
tumor  during  pregnancy  than  during  nursing. 

Diffuse  Bilateral  Gravidity  Hypertrophy. — The  bilateral  hj-per- 
trophy  observed  in  virgins  after  puberty  may  be  observed  in  the 
breasts  during  pregnancy.  As  far  as  I  can  learn  from  the  literature, 
it  is  a  rare  condition.  If  these  breasts  produce  milk,  and  the  child 
nurses,  the  condition  as  a  rule  spontaneously  recovers.     If,  however, 


564 


REGIONAL    SURGERY 


there  is  no  secretion  of  milk,  spontaneous  recovery  rarely,  if  ever, 
takes  place. 

Lactation. — The  predominant  lesion  of  the  lactating  breast  is 
mastitis.  The  portal  of  entrance  of  the  infection  is  through  the  in- 
jured nipple.  The  suckling  child  is  apt  to  injure  the  nipple  within  the 
first  few  months.  Lactation  mastitis  is  most  frequent  within  the  first 
month,  and  very  rarely  observed  after  the  fourth  month. 


^«t  7(1  c/oce/e. 


Fig.  302. — Galactocele — a  single  cyst  containing  milky  fluid.     The  breast  contains  dilated 

ducts  with  milky  fluid. 

Pathol.  No.  10948. — 1910,  complete  operation  for  cancer  on  account  of  retracted  nipple 
and  red,  adherent  skin. 

White,  female,  aged  40;  a  mastitis  in  this  breast  many  years  ago  leaving  retracted  nipple ; 
at  the  time  of  the  operation  patient  was  nursing  child  two  years  of  age.  Tumor  observed 
three  months.  Rapid  growth;  painful  and  tender.  The  changes  in  the  skin  were  probably 
due  to  an  infection  of  the  galactocele.  The  microscopic  study  shows  chronic  mastitis 
(see  Fig.  314)  and  dilated  ducts  (see  Fig.  318)  and  some  areas  of  lactation  hypertrophy  (see 
Fig.  323)- 


A  lump,  or  a  "cake,"  or  an  induration  of  the  breast  in  the  first 
four  months  of  lactation  may  at  first  be  looked  upon  as  mastitis. 
We  should  expect  in  such  a  palpable  area  resolution  (spontaneous 
disappearance),  or  the  formation  of  a  definite  abscess  (relieved  by 
incision).  If  one  of  these  two  things  does  not  take  place  within  two 
weeks,  one  should  be  suspicious  of  malignancy.     The  area  should  be 


LESIONS    OF   THE    FEMALE   BREAST  565 

explored.  The  chronic  mastitis  abscess  (Fig.  303)*  and  galactocele 
(Fig.  302)  must  be  distinguished  in  the  gross  from  the  cancer  cyst  (Fig. 
305).  Tuberculosis  (Fig.  304)  may  be  recognized  by  the  abscess. f 
The  non-suppurating  chronic  mastitis  is  most  diflScult  tojdifferentiate 
from  cancer.  The  benign  tumor  will  be  found  encapsulated  (Fig.  306). 
The  dilemma  here  will  come  in  the  frozen  section  (Fig.  307).] 


Fig.  303. — Chronic  mastitis  in  a  lactating  breast,  from  the  wall  of  a  chronic  lactation 

mastitis  abscess. 

Pathol.  No.  228. — 1893,  excision  of  cyst;  later  complete  operation  for  cancer,  on  account 
of  the  microscopic  picture  shown  here.      1916,  23  years,  well. 

White,  female,  aged  29;  nursing  child  four  months  old;  tumor  two  months.  Clinically 
and  gross  a  chronic  abscess;  surrounding  breast  shows  normal  lactation  with  a  zone  of  mas- 
titis adjacent  to  abscess  cavity. 

In  lactation  the  nipple  should  always  be  protected.  When  the 
cake  appears  massage  is  not  sufficiently  beneficial  in  mastitis  to  justify 
its  employment  while  it  would  be  distinctly  dangerous  if  the  lesion 
were  malignant.  Cleansing  and  protection  of  the  infected  nipple 
are  the  most  important  things  in  the  treatment.  Bier's  hyperemia, 
ice,  or  the  hot-water  bag  may  be  employed.  My  personal  experience 
is  too  limited  to  speak  authoritatively.  I  have  confined  my  treat- 
ment to  the  nipple  and  to  ice  and  have  been  surprised  at  the  large 

*  All  these  photographs  were  taken  by  Mr.  Herman  Schapiro. 

t  Tubercular  mastitis  without  abscess  shows  no  caseation.  It  resembles  lactation 
mastitis  without  abscess.  Both  suggest  infiltrating  carcinoma.  Both  in  the  gross  and 
the  frozen  section. 


566 


REGIONAL   SURGERY 


Fig.  304. — Tuberculous  abscess  of  breast.     Cavity  lined  by  tuberculous  granulation 

tissue. 
Pathol.  No.  19066.— Operation  in  1916,  complete  excision  of  the  breast. 


Fig.  305. — Cancer  cyst  in  senile  breast. 
Pathol.  No.  7665. — Complete  operation  for  cancer. 


LESIONS  OF  THE  FEMALE  BREAST 


567 


number  of  cases  of  spontaneous  disappearance.  If  ice  should  give 
discomfort — do  nothing.     On  the  first  signs  of  pus — incise. 

For  abnormahties  in  lactation,  especially  the  scanty  secretion 
of  milk,  I  shall  take  no  space. 

Mastitis. — The  history  of  "caking'^  of  the  breast  during  lactation,  of 
a  definite  mastitis  which  disappeared  spontaneously,  or  of  an  abscess 
which  was  incised  or  ruptured  spontaneously,  must  be  considered  in 
the  differential  diagnosis. 

The  history  of  a  lump  appearing  during  lactation,  or  remaining 
after  lactation  is  suggestive  of  a  galactocele  (Fig.  302).  At  the  present 
time  our  records  are  meager  in  regard  to  this  interesting  breast  lesion. 

Malignant  tumors  of  the  breast  have  apparently  no  relation  to 
a  mastitis  which  disappears  spontaneously,  or  forms  an  abscess  which 
heals.     However,  if  the  induration  in  the  area  of  the  mastitis,  whether 


Fig.  306. — Encapsulated  fibroadenoma  removed  with  a  zone  of  breast;  stroma  in  excess. 
Pathol.  No.  9340. — Operation  in  1908.     White,  female,  aged  19;  tumor  four  weeks.     In 

19 1 6,  eight  years,  well. 

there  has  been  an  abscess  or  not,  does  not  disappear,  cancer  may 
develop  in  this  area  (Fig.  308). 

These  two  facts — the  occurrence  of  galactocele  and  cancer  in  old 
scars  after  mastitis — represent  additional  evidence  to  emphasize  the 
dictum  that  no  lump  in  the  breast  can  be  considered  innocent,  and 
except  in  girls  under  twenty-live  and  during  lactation,  every  lump  in 
the  breast  should  immediately  be  explored. 

In  the  lactating  breast,  in  view  of  the  common  occurrence  of 
mastitis,  we  are  justified  in  watching  the  indurated  area  for  a  short 
period,  but  in  the  absence  of  complete  resolution  or  pus  formation, 
the  doubtful  area  should  be  explored.  When  there  are  indurated 
scars  after  a  mastitis,  these  should  be  excised  with  a  good  margin  of 
healthy  breast. 

Mastitis,  except  during  lactation,  is  a  rare  disease,  and  one  should 
never  make  a  clinical  diagnosis,  but  should  explore  the  area. 


568 


REGIONAL   SURGERY 


Fig.  307. — Lactation  hj'pertrophy  in  an  encapsulated  fibroadenoma. 
Pathol.  No.  15518. — Operation  in  1914,  excision  of  tumor  and  zone  of  breast.     White, 
female,  aged  20;  tumor  three  months;  patient  pregnant  two  months.     1916,  two  years,  well. 
Pregnancy  and  lactation  not  disturbed  by  operation. 


Fig.  308. — Scirrhous  carcinoma  developing  in  the  scar  residual  from  chronic  mastitic. 
The  ducts  with  their  thickened  walls  preserved. 


LESIONS    OF   THE    FEMALE  BREAST  569 

Mastitis  and  Lactation. — Lactation  may  persist  if  the  child  is  allowed 
to  nurse,  in  spite  of  the  presence  of  single  or  multiple  abscesses.  Nor 
do  the  latter  necessarily  interfere  with  lactation  after  a  subsequent 
pregnancy. 

Menstruation. — The  relation  of  breast  lesions  to  diseases  of  the 
pelvic  organs  needs  much  more  data  before  it  can  be  defined.  We 
know  that  with  pregnancy  the  breast  immediately  undergoes  a  paren- 
chymatous hypertrophy.  The  fully  developed  secretion  of  milk,  to  be 
maintained,  is  apparently  dependent  upon  irritation  of  the  nipple. 
Lactation  ceases  and  the  breasts  return  to  normal  when  the  child 
ceases  to  nurse. 

There  is  some  evidence  to  suggest  that  there  may  be  parenchyma- 
tous changes  in  the  breast  associated  with  pelvic  conditions  other 
than  pregnancy.  The  lesion  of  the  breast  called  chronic  cystic  mastitis 
is  most  frequent  during  the  period  called  the  menopause. 

The  relation,  however,  between  pelvic  lesions,  the  menstrual* 
period,  and  breast  lesions  is  not  sufficiently  well  established  to  be 
helpful  in  the  differential  diagnosis. 

Menopause. — It  is  quite  true  that,  except  for  cysts  and  chronic 
cystic  mastitis,  benign  tumors  are  rare  after  the  menopause,  but  the 
number  of  the  former  (cysts)  is  sufficiently  large  not  to  justify  the 
complete  operation  for  cancer  of  the  breast  in  women  after  the  meno- 
pause without  exploratory  incision. 

Children. — Most  careful  studies  have  been  made  on  the  relation 
of  the  different  forms  of  breast  lesions  in  unmarried  women,  in  married 
women  who  have  borne  no  children,  in  married  women  who  have 
borne  children,  and  the  character  of  the  lactation  in  the  latter.  These 
data  are  rarely,  if  ever,  helpful  in  the  differential  diagnosis,  and  al- 
though of  interest  to  record,  they  must  not  be  allowed  to  weigh  much, 
if  at  all,  in  the  differentiation  between  a  benign  and  a  malignant  tumor. 
It  is  true  that  chronic  cystic  mastitis  is  much  more  frequent  in  the 
breast  which  has  never  lactated,  whether  there  had  been  pregnancy,  or 
not.  When,  therefore,  you  see  a  woman  reaching  the  menopause, 
whose  breasts  have  never  lactated,  who  comes  to  you  because  of  pain 
in  the  breast  and  the  feeling  of  an  indefinite  lump,  and  you  find  in  this 
and  in  the  other  breast  other  lumps  just  as  indefinite  as  the  one  the 
patient  has  felt,  you  probably  will  be  safe  in  diagnosing  bilateral  chronic 
cystic  mastitis,  for  which  operation  is  not  indicated  at  this  time.  I 
will  consider  this  point  again,  as  many  breasts  now  are  being  sacrificed 
for  certain  stages  of  this  disease. 


570  REGIONAL   SURGERY 

HISTORICAL  DATA 

Up  to  the  present  time  an  intensive  study  of  the  data  thus  briefly 
discussed  has  shown  that  with  rare  exceptions  they  cannot  be  depended 
upon  for  differential  diagnosis.  Perhaps  future  studies  may  find  some 
diagnostic  points.  I  am  confident  that  in  many  cases  precious  time 
has  been  lost  by  allowing  data  of  this  kind  to  influence  the  diagnosis 
and  the  decision  as  to  operative  intervention.  I  have  not  mentioned 
the  family  history  of  cancer  or  tuberculosis  and  purposely  so,  because 
its  presence  or  absence  should  have  no  influence  on  the  surgeon's 
conclusions. 

SYMPTOMS  OF  ONSET 

/  have  called  attention  to  these  in  the  first  paragraph.  The  most 
frequent  symptom  is  the  palpation  of  a  tumor,  and  if  we  could  educate 
women  to  pay  immediate  attention  to  this  one  message,  the  number  of 
deaths  from  cancer  of  the  breast  would  be  immediately  diminished. 
Confusion  has  been  caused  in  the  minds  of  women  by  other  possible 
symptoms,  especially  pain.  The  woman  usually  waits  for  pain,  and 
in  the  past,  when  a  physician  was  asked  to  see  the  lump,  he  usually 
waited  for  the  so-called  clinical  signs  of  cancer — retracted  nipple, 
adherent  skin,  ulceration;  and  he  thought  much  about  the  presence  or 
absence  of  palpable  glands  in  the  axilla. 

The  majority  of  women  are  warned  by  a  lump,  and  that  warning 
should  be  enough.  If  the  physician  can  feel  a  lump,  it  is  fortunate 
for  the  patient  if  nothing  else  can  be  made  out  on  examination. 

Pain. — Pain  is  neither  a  sign  of  cancer,  nor  necessarily  of  any 
dangerous  lesion  in  the  breast.  Pain  in  one  or  both  breasts  is  not 
uncommon  in  women  just  before  the  menstrual  period  and  disappears 
after  the  beginning  of  the  flow.  As  tingling  of  the  breasts  may  be  the 
first  suggestion  of  pregnancy,  so  pain  in  the  breast  may  be  the  first 
warning  of  the  coming  menstrual  period.  Undoubtedly  many  women 
experience  these  discomforts  and  say  nothing  about  them. 

Up  until  1 910  I  have  records  of  but  6ve  patients  who  came  under 
observation  for  pain  only;  the  duration  of  this  pain  had  varied  from 
three  weeks  to  four  years.  In  none  of  these  cases  has  any  disease  of 
the  breast  developed.  Since  1910  there  are  records  of  12  cases;  the 
duration  of  the  pain  has  varied  from  four  days  to  two  years. 

The  most  common  factor  in  all  of  these  cases  is  that  the  women 
are  usually  approaching  the  menopause,  and  naturally  one  thinks  of 


LESIONS   OF   THE   FEMALE   BREAST  57 1 

chronic  cystic  mastitis.  We  know  that  at  autopsy  small  cysts  and 
dilated  ducts  are  present  in  at  least  25  per  cent,  of  the  breasts  of  all 
women  over  40  years  of  age. 

The  next  most  frequent  historical  fact  is  the  fear  of  cancer.  These 
patients  have  had  some  near  relative  or  friend  die  of  cancer,  and  then 
experienced  pain  in  the  breast.  In  our  seventeen  patients  there  are 
but  three  under  30  years  of  age;  the  youngest  was  twenty-three. 

The  thing  which  should  interest  us  most  is  whether  pain  in  the 
breast  is  a  forerunner  of  some  disease  and  if  so,  of  what  form. 

In  the  great  majority  of  cases,  when  pain  is  the  first  symptom 
and  tumor  the  second,  the  tumor  is  benign. 

Nevertheless  in  a  record  of  almost  1800  cases  there  is  not  a  single 
variety  of  benign  or  malignant  condition  of  the  breast  in  which,  in 
some  cases,  pain  had  not  been  the  first  symptom  observed. 

However,  if  nothing  is  found  on  palpation,  pain  is  not  an  indica- 
tion for  operation.  Of  course,  such  patients  should  be  carefully 
watched.  Future  intensive  investigation  may  disclose  a  few  instances 
in  which  pain  alone  may  be  relied  upon  as  an  indication  for  the  removal 
of  the  breast. 

Discharge  of  Blood  from  the  Nipple. — There  is  a  prevailing  view 
that  a  bloody  discharge  from  the  nipple  means  cancer,  and  that  the 
complete  operation  for  cancer  should  be  performed.  This  conclusion 
is  apparently  based  on  records  different  from  my  own,  or  on  incorrect 
observations. 

My  experience  shows  that  if  there  is  no  other  sign  or  symptom, 
except  discharge  of  blood  from  the  nipple,  there  is  no  more  indication 
for  operation  than  in  the  presence  of  pain  alone.  I  am  hopeful, 
however,  to  be  able  some  day  to  recognize  the  few  cases  in  which 
discharge  from  the  nipple  can  be  properly  interpreted  as  an  indication 
for  the  removal  of  the  breast. 

In  876  cases  of  cancer  of  the  breast  discharge  from  the  nipple 
has  been  the  first  symptom  in  but  16  cases  (less  than  2  per  cent.).  In 
the  majority  of  these  the  tumor  was  felt  at  the  same  time  or  within 
a  few  days  after  the  discharge  was  noted.  In  a  few  cases  the  interval 
was  months,  in  two  cases  only  was  the  interval  a  year. 

Among  716  cases  of  benign  tumors  of  the  breast  discharge  from 
the  nipple  has  been  the  symptom  of  onset  in  twenty-four  (slightly 
over  3  per  cent.).  In  the  majority  of  these  cases  the  tumor  proved 
to  be  an  intracystic  papilloma.     In  fact,  it  is  a  question  whether 


572  REGIONAL   SURGERY 

such  an  intracystic  papilloma  was  not  present  in  every  case  subjected 
to  operation. 

In  nine  cases  of  discharge  of  blood  from  the  nipple  in  which  nothing 
else  could  be  made  out,  no  operation  was  performed,  and  no  tumor 
developed.  In  this  group  there  are  four  cases  in  which  the  interval 
is  II  years  or  more;  the  others  are  more  recent — four  years  or  less. 
The  longest  duration  of  a  bloody  discharge  without  the  development  of 
a  tumor  was  three  years. 

We  have,  therefore,  no  evidence  that  discharge  from  the  nipple 
is  an  indication  of  malignant  disease,  but  cases  of  this  kind  should 
be  carefuUy  watched,  and  the  patient  should  be  instructed  how  to 
keep  the  nipple  scrupulously  clean. 

Retraction  of  the  Nipple. — The  sudden  appearance  of  retraction 
of  the  nipple  is  a  sign  of  entirely  different  significance  from  that  of 
discharge  of  blood  from  the  nipple.  It  is  usually  the  warning  of 
malignant  disease  of  the  breast.  It  may  be  present,  but  very  rarely, 
in  benign  conditions.  If  one  can  establish  that  the  retraction  of 
the  nipple  is  really  of  recent  appearance  and  is  not  a  congenital,  or 
old  affair  from  some  former  lactation  mastitis,  it  should  be  looked 
upon  as  indicating  a  malignant  tumor  in  the  breast  and  the  entire 
breast  removed,  or  the  complete  operation  for  cancer  done. 

Retraction  of  the  nipple  may  be  a  congenital  condition,  but  this 
type  of  depressed  nipple  as  a  rule  is  different  from  the  acquired  re- 
traction. Retraction  of  the  nipple  may  take  place  after  a  mastitis 
with  or  without  abscess  formation,  and  now  and  then,  when  the  child 
is  suddenly  taken  from  the  breast,  one  or  both  nipples  may  pull  in 
without  evidence  of  mastitis. 

In  a  few  instances  with  distinctly  benign  lesions  retraction  of 
the  nipple  has  been  the  first  symptom  observed,  chiefly  in  chronic 
cystic  mastitis. 

At  the  present  time  it  is  my  opinion  that  it  is  safer  to  look  upon 
this  type  of  retraction  of  the  nipple  as  a  definite  sign  of  cancer.  If 
nothing  else  can  be  made  out,  it  is  my  practice  to  completely  remove  the 
breast  with  the  pectoral  fascia  to  the  axilla;  to  clamp  the  axilla  and 
cut  it  off  with  the  cautery;  then  make  serial  sections  into  the  breast; 
if  cancer  is  found,  proceed  with  the  axillary  operation;  if  not,  remove 
the  axillary  tissue  beyond  the  clamp. 

If  cancer  is  not  found,  a  condition  of  the  breast  is  usually  present 
best  treated  by  complete  removal  of  the  breast. 

I  have  been  surprised  at  the  attitude  of  many  experienced  clin- 


LESIONS    OF   THE    FEMALE   BREAST  573 

icians  and  surgeons  towards  this  retraction  of  the  nipple  when  it 
has  been  the  only  sign  present.  Precious  time  has  been  lost  waiting 
for  the  appearance  of  the  tumor.  As  a  rule  in  these  cases  the  cancer 
is  in  the  nipple  zone  and  difiEicult  to  recognize  by  palpation,  or  the 
women  have  large,  fat  breasts,  and  the  little  scirrhus  is  too  deeply 
situated  to  be  recognized. 

Pain  and  discharge  from  the  nipple  are  messages,  but  require 
no  answer.  Retraction  of  the  nipple  is  a  message  which  should  receive 
immediate  attention. 

Ulceration  of  the  Nipple  (Paget's  Disease). — Years  ago  Paget 
described  a  number  of  cases  of  cancer  of  the  breast  associated  with 
ulceration  of  the  nipple.  In  this  special  group,  Paget  states,  the 
ulceration  of  the  nipple  has  begun  one  or  more  years  before  the  patient 
had  felt  the  lump  in  the  breast.  As  far  as  I  know,  there  are  no  recorded 
cures,  when  the  operation  has  been  performed  in  the  Paget  stage. 

The. sore  nipples  during  lactation  require  great  care  and  give  anxiety 
chiefly  in  relation  to  mastitis. 

There  may  also  be  a  syphilitic  ulceration  of  the  nipple  in  the 
nursing  mother,  but  other  symptoms  on  the  part  of  mother  and  child 
should  excite  suspicion,  and  the  Wassermann  test  will  do  the  rest. 

Any  irritation,  or  eczema,  or  ulceration  about  the  nipple  and 
areola  should  receive  immediate  attention.  In  some  cases  copious 
use  of  soap  and  water  will  cure  the  disease.  In  others  there  will 
be  a  positive  Wassermann.  When  cleanliness  fails  to  reUeve  and 
the  blood  examination  is  negative,  I  am  confident  that  it  will  be  safer 
to  look  upon  this  lesion  of  the  nipple  just  as  we  have  decided  to  regard 
retraction  of  the  nipple — as  a  sign  of  cancer.  Nothing  can  be  gained 
by  excising  a  piece  for  diagnosis,  or  completely  excising  the  nipple 
zone.  The  breast  should  be  removed  or  the  complete  operation  for 
cancer  performed.  Not  all  of  these  cases  are  cancer,  but  I  am  unable, 
from  the  available  data,  to  tell  how  to  differentiate  the  benign  from 
the  malignant.  I  am  confident  that  the  mutilation  should  be  con- 
sidered less,  than  the  greater  risk  of  any  conservative  operation. 

Subcutaneous  Fat. — In  the  normal  breast  the  nipple,  the  areola 
and  the  skin  are  freely  movable  over  the  deeper  structures,  and  there 
is  always  a  zone  of  subcutaneous  fat  between  the  skin  and  the  breast, 
except  beneath  the  nipple.  When  one  can  palpate  a  small  tumor,  the 
demonstration  of  absence  of  subcutaneous  fat  between  the  skin  and 
the  tumor  is  a  sign  of  malignancy.  In  large  tumors  it  is  possible 
to  have  an  atrophy  of  this  fat  from  pressure  in  lesions  distinctly  benign. 


574 


REGIONAL   SURGERY 


Atrophy  of  the  subcutaneous  fat  may  also  be  observed  in  pyogenic  and 
tuberculous  mastitis. 

The  demonstration  of  atrophy  of  the  subcutaneous  fat  is  rather 
an  expert  procedure ;  it  is  one  of  the  earliest  signs  of  cancer. 

In  \drginal  and  gravidity  bilateral  hypertrophy  the  parenchyma 
and  stroma  of  the  hyperplastic  breast  tissue  may  replace  the  subcutan- 
eous fat  and  bring  the  breast  tissue  immediately  beneath  the  skin. 
But  in  this  disease  it  is  not  a  sign  of  malignancy. 

Skin. — Only  once  have  I  observed  discreet  skin  metastasis  in  a 
breast  tumor  otherwise  apparently  benign,  and  in  this  case  the  two 


Fig.  309. — Bulging  of  tumor.     No  dimpling  of  skin  over  a  simple  cyst  in  chronic  cystic 

mastitis. 
Path.  No.  8579. — White,  female,  aged  52.     Tumor  one  year.     Operation,  1907,  excision 
of  cyst  and  zone  of  breast.     1916,  nine  years,  well.^^ 


little  nodules  were  present  in  the  zone  of  skin  directly  over  the  breast 
tumor.  There  is  no  way  to  distinguish  a  single  metastatic  skin  nodule 
from  the  common  fibroma  of  the  skin.  Fortunately  the  latter  is  very 
rare  in  the  breast  area,  but  I  have  observed  two  cases  of  benign  breast 
tumors  in  which  there  were  also  present  single,  shot-like  skin  nodules 
which   were   fibromas.     This   possibility   should   be   borne   in   mind, 


LESIONS    OF   THE    FEMALE   BREAST 


575 


and  one  should  not  make  a  diagnosis  of  malignant  tumor  of  the  breast 
because  of  a  single  skin  nodule. 

The  changes  in  the  skin  which  are  rarely  associated  with  benign 
tumors  are  dhnpling  and  slight  fixation.  The  dimpling  is  brought 
out  by  pushing  the  breast  with  the  palpable  tumor  with  both  hands 
(Figs.  309  and  310).  Fixation  is  elicited  by  picking  up  a  bit  of  skin  over 
the  tumor. 

These  two  early  signs  of  cancer  have  now  and  then  been  observed 
in  benign  lesions,  especially  simple  cysts. 


Fig.  310. — Dimpling  of  the  skin  over  the  bulging  tumor.     Small  infiltrating  scirrhus. 

Path.  No.  7973. — White,  female,  aged  54.     Tumor  six  weeks,  pain  10  days.     Complete 

operation,  1907.     No  metastasis  to  axilla.     1916,  nine  years,  well. 


Redness  and  definite  adhesion  of  the  skin  to  the  tumor  are  ob- 
served in  pyogenic  and  tuberculous  mastitis,  and  in  infected  cysts 
(which  are  very  rare).  In  the  vast  majority  of  cases  they  are  signs 
of  cancer.  Very  large  benign  tumors  (intracanalicular  myxoma)  may 
by  pressure  produce  ulceration  of  the  skin.  With  this  exception 
ulceration  is  an  almost  positive  sign  of  cancer. 

The  formation  of  a  sinus  or  sinuses  is  very  unusual  in  a  malignant 
tumor  of  the  breast.  It  is  very  common  in  tuberculosis  after  the 
sixth  month.  The  early  formation  of  a  sinus  favors  a  pyogenic  abscess. 
This  latter  should  heal  rapidly,  while  the  sinus  from  a  tuberculous  focus 
rarely  heals. 


576  REGIONAL   SURGERY 

When  a  malignant  breast  tumor  becomes  infected,  forms  an  abscess, 
becomes  adherent  to  the  skin,  ruptures  and  forms  a  sinus,  the  dif- 
ferential diagnosis  from  mastitis,  pyogenic  or  tuberculous,  is  practically- 
impossible  clinically.  Although  it  is  very  rare  in  malignant  disease, 
the  evidence  seems  to  indicate  that,  in  cases  of  this  kind,  it  is  a  safer 
procedure  to  operate  for  cancer.  In  most  of  these  cases  the  breast 
must  be  removed  in  any  event.  In  a  few  instances  one  with  a  large 
experience,  having  recognized  the  benign  character  of  the  lesion, 
may,  with  comparative  safety,  perform  a  conservative  operation. 

In  a  few  instances  a  local  infection  in  the  skin  over  the  breast  may 
involve  the  deeper  tissues  and  produce  a  clinical  picture  suggesting 
malignant  disease.     Here  a  careful  history  will  be  helpful. 

The  later  changes  in  the  skin  associated  with  fully  developed 
cancer  should  give  rise  to  no  difficulty,  and  although  now  and  then 
these  may  be  associated  with  mastitis,  it  is  always  the  safer  pro- 
cedure to  operate  for  cancer.  These  more  definite  skin  changes 
are  the  so-called  "pig  skin,"  marked  induration,  multiple  dimpling, 
superficial  ulceration,  reddening,  dilatation  of  veins. 

QEdema  of  the  skin  and  subcutaneous  tissue  over  the  breast  is 
usually  a  sign  not  only  of  cancer,  but  of  hopeless  cancer.  I  have, 
however,  observed  it  twice  in  benign  conditions  of  the-  breast.  In 
both  instances  the  breasts  were  large  and  pendulous,  the  induration 
of  the  breast  and  oedema  of  the  skin  and  fat  had  followed  a  trauma 
and  had  persisted. 

Axilla. — Too  much  importance  has  been  placed  upon  the  presence 
or  absence  of  palpable  nodules  in  the  axilla,  and  so  far  the  recent 
teaching  has  been  unable  to  overcome  the  older.  In  benign  lesions 
of  the  breast,  glands  are  frequently  palpable;  in  cancer  of  the  breast 
with  metastasis  to  the  glands  in  the  axilla,  one  may  be  unable  to  palpate 
glands. 

In  my  entire  experience  I  have  only  observed  one  case  in  which  the 
palpation  of  large  and  adherent  glands  in  the  axilla  led  to  a  diagnosis 
of  malignancy  even  in  the  absence  of  any  palpable  lump  in  the  breast. 
After  the  complete  operation  a  small  schirrous  cancer  was  found  in  the 
breast.     This  woman,  however,  had  a  large,  fatty  breast. 

In  a  small  number  of  cases  of  cancer  of  the  breast  the  patient's  atten- 
tion to  the  disease  has  been  attracted  by  the  nodules  in  the  axilla,  and 
the  tumor  of  the  breast  was  not  felt  until  later.  But  this,  of  course, 
does  not  exclude  the  presence  of  the  breast  tumor  at  that  time. 

When  one  feels  a  palpable  mass  or  a  number  of  enlarged  glands  in 


LESIONS    OF   THE    FEMALE  BREAST  577 

the  axilla  and  palpation  fails  to  reveal  any  trouble  in  either  breast,  there 
should  first  be  a  blood  examination  to  exclude  leukemia  or  syphilis. 
Having  excluded  these,  the  probabilities  are  that  one  is  dealing  with  a 
primary  lesion  within  the  axillary  area.  The  number  of  such  cases  is 
small.  We  must  first  bear  in  mind  aberrant  breast  tissue.  Tumors 
of  this  kind  feel  like  lipomas.  I  will  discuss  them  later.  Then  there 
are  a  few  examples  of  hypertrophy  and  infection  of  the  axillary  sweat 
glands.  The  most  common  benign  tumors  in  the  axilla  are  lipoma  and 
fibromyxoma  of  nerve  sheaths. 

We  must  also  bear  in  mind  that  the  glands  may  be  enlarged  from 
pyogenic  or  tuberculous  infection  through  a  portal  of  entrance,  situated 
at  a  distance,  but  which  has  healed,  and  the  patient  may  have  forgotten 
the  incident.     (Healed  wounds  of  fingers.) 

Sarcoma  of  glands,  nerve  sheaths  and  fascia  are  possible. 

In  the  surgical  attack  on  axillary  masses  without  breast  involvement 
the  mistake  is  usually  made  of  performing  an  incomplete  operation  on 
the  clinical  diagnosis  of  a  benign  lesion.  If  these  cases  are  carefully 
considered,  one  should  be  able  to  recognize  those  in  which  a  complete 
axillary  dissection  offers  the  patient  the  best  opportunity  of  a  cure,  and 
in  my  experience,  whenever  such  an  axillary  dissection  is  indicated,  it 
is  best  to  perform  the  so-called  complete  operation  for  cancer  of  the 
breast. 

Supraclavicular  Glands. — The  involvement  of  these  glands  is  a 
late  occurrence  in  cancer  of  the  breast.  The  decision  as  to  when  to 
explore  the  neck  depends  less  upon  palpation  before  operation,  than 
upon  the  findings  within  the  axilla  at  operation.  This  will  be  discussed 
under  operation. 

Other  Breast. — Both  breasts  should  always  be  carefully  palpated. 
The  finding  in  the  other  breast  of  single  or  multiple  tumors  is  a  factor 
in  favor  of  benignity,  which  will  be  discussed  again  under  tumor. 

We  often  now  see  patients  with  a  lesion  of  one  breast,  and  a  history 
of  some  condition  in,  or  operation  on,  the  other  breast.  For  example, 
there  may  be  a  history  of  a  disappearing  tumor,  discharge  from  the 
nipple,  or  pain.  This  is  suggestive  that  we  are  deaUng  with  a  bilateral 
lesion  which  in  the  majority  of  cases  is  benign,  usually  a  simple  cyst  or 
an  intracystic  papilloma. 

When  there  is  a  history  of  removal  of  a  tumor  from  the  other  breast 

and  no  evidence  of  recurrence,  we  have  evidence  that  this  tumor  at  least 

was  benign.     But  unless  we  have  absolute  proof  of  the  nature  of  this 

tumor,  we  are  not  helped.     Should  we  know  positively  that  the  removed 

37 


578  REGIONAL   SURGERY 

tumor  was  a  cyst  or  an  intracanalicular  myxoma,  this  evidence  would 
favor  a  benign  tumor  in  the  breast  under  examination. 

Among  almost  200  cases  of  simple  cysts  of  the  breast  we  have  seen 
cancer  of  the  remaining  breast  once  only.  This  indicates  that  if  a 
patient  has  a  cyst  in  one  breast  and  then  a  tumor  develops  in  the  other 
breast,  the  chances  are  that  the  second  tumor  is  also  a  cyst.  The  same 
is  also  true  of  intracanalicular  myxoma. 

With  these  two  exceptions  the  knowledge  of  a  previous  tumor  of 
the  other  breast  is  not  helpful,  except  when  we  know  that  the  first 
tumor  removed  was  a  cancer.  This  is  very  suggestive  that  the  present 
tumor  is  also  malignant. 

Our  observations  show  that  the  longer  our  patients  live  after  an 
operation  for  cancer  of  one  breast,  the  greater  the  probability  of  cancer 
of  the  other  breast.  As  yet  we  have  not  sufficient  evidence  to  prog- 
nosticate this  occurrence  and  to  justify  the  removal  of  the  other  breast 
as  a  protective  measure. 

Bilateral  diseases  of  the  breast  will  be  discussed  under  multiple 
tumors. 

Other  Organs. — /  have  no  evidence  that  would  he  helpful  in  the  dif- 
ferential diagnosis  of  breast  tumors  by  the  finding  of  lesions  elsewhere. 
In  older  literature  there  is  much  stress  laid  upon  cases  in  which  the 
symptoms  of  metastasis  were  the  first  signs  of  cancer  of  the  breast, 
especially  fracture  of  the  neck  of  the  femur  and  paralysis  of  the  lower 
limbs.  But  apparently  in  these  cases  the  breast  lesion  was  overlooked 
by  patient  and  physician  in  a  way  not  likely  to  occur  today.  The  only 
fact  that  has  impressed  me  in  a  long  observation  is  that  we  rarely  see 
cancer  of  the  breast  in  women  with  marked  tuberculosis  of  the  lungs, 
while  in  our  cases  of  tuberculosis  of  the  breast  lung  involvement,  if 
present,  is  slight. 

Vague  pains  in  the  chest,  in  bones  and  joints,  which  as  a  rule  are 
the  first  signs  suggesting  metastasis  after  operation,  cannot  be  inter- 
preted before  operation  as  an  indication  of  metastasis.  Again  and 
again  I  have  observed  them  before  operation  in  patients  who  have 
remained  well  years  after  the  complete  operation  for  cancer. 

Patients  with  lesions  of  the  breast  should  receive  a  most  careful 
general  investigation,  but  up  to  the  present  time  it  has  not  been 
especially  helpful  in  the  exact  diagnosis  of  the  condition  in  the  breast. 

I  am  now  investigating  the  relation  of  chronic  cystic  mastitis  to 
pelvic  lesions,  but  as  yet  have  obtained  no  definite  data. 

As  a  rule  our  patients  with  breast  tumors  are  good  operative  risks. 


LESIONS    OF   THE    FEMALE   BREAST  579 

One  should  always  think  of  the  ribs  below  the  breast  as  the  possible 
focus  of  the  breast  lesion.  I  have  seen  this  occur  but  twice.  Both 
were  instances  of  post-typhoid  perichondritis  in  which  the  pus  had 
infiltrated  the  breast.  In  one  of  these  at  exploration  we  found  an 
abscess,  in  the  other  an  encapsulated  bone  sequestrum. 

Single  Tumor. — In  the  vast  majority  of  cases  the  patient  first 
observes  a  single  tumor,  and  if  she  seeks  advice  at  once,  this  is  all 
that  will  be  found  at  examination. 

I  have  learned  that,  when  a  woman  comes  under  observation  com- 
plaining of  a  breast  lesion,  it  is  a  safer  plan  to  at  first  take  no  history 
and  caution  the  patient  not  to  tell  you  which  breast  is  involved. 
In  the  past  two  years  this  plan  has  been  especially  useful  because  of 
the  greater  number  of  women  who  are  seeking  advice  early  for  vague 
pain,  indefinite  lumps  and  slight  weeping  from  one  or  both  nipples. 
If  after  examining  both  breasts  most  carefully  you  can  feel  no  distinct 
lump,  or  if  the  indistinct  area  which  you  feel  is  not  the  one  the  patient 
felt,  the  chances  are  there  is  no  definite  tumor.  When  a  patient  tells 
even  an  experienced  surgeon  that  she  has  a  lump  in  the  upper  and 
outer  quadrant  of  the  right  breast,  there  is  a  tendency  for  him  to  feel 
this  lump. 

The  breasts  of  many  women  are  lumpy.  This  is  most  marked  just 
before  and  in  the  beginning  of  menstruation  in  all  women.  In  un- 
married girls  palpation  produces  congestion  and  the  suspicion  of 
a  lump,  but  in  these  cases  the  age  under  twenty-five  helps  to  ex- 
clude cancer.  Now  and  then,  however,  such  breasts  are  explored  and 
no  tumor  is  found.  In  older  women  who  have  nursed  children  and 
in  younger  women  who  have  not,  lumpy  breasts  are  a  common  finding, 
especially  toward  the  menopause. 

Now  that  women  are  seeking  advice  so  early,  we  should  be  particu- 
larly anxious  not  to  overlook  a  single  tumor.  But  at  the  same  time 
we  do  not  wish  to  subject  them  to  unnecessary  operation. 

We  must  also  bear  in  mind  that  a  patient  may  have  felt  a  tumor, 
and  the  previous  examiner  may  also  have  been  correct,  but  when  you 
examine  the  patient  there  is  no  tumor.  You  may  also  feel  the  tumor 
at  your  first  examination  and  fail  to  find  it  at  the  next.  This  is  the 
disappearing  tumor — a  simple  or  papillomatous  cyst,  and  its  dis- 
appearance is  almost  as  good  a  cure  as  its  removal  by  operation. 

The  demonstration  of  a  definite  single  tumor  is  an  indication 
for  immediate  operation  when  the  patient  is  over  25  years  of  age, 
and  with  rare  exceptions  the  operation  is  also  indicated  in  women 


580  REGIONAL    SURGERY 

over  twenty.  The  function  of  a  breast  is  not  injured  by  the  removal 
of  a  single  tumor,  and,  if  this  tumor  is  benign,  the  patient  is  protected 
by  the  removal  of  a  precancerous  lesion. 

The  object,  however,  of  operating  upon  a  single  tumor  is  not 
so  much  to  remove  a  benign  lesion  as  to  expose  and  recognize  a  pos- 
sible cancer  in  a  period  when  the  chances  of  a  permanent  cure  are 
best. 

Disappearing  Tumors. — I  have  records  of  nine  cases  of  tumors 
which  have  disappeared  when  felt  after  a  most  careful  examination. 
The  age  of  these  patients  was  under  thirty  in  three,  in  four  it  was 
between  thirty  and  forty,  and  in  one  forty-five.  So  far  in  this  group 
no  other  tumors  have  appeared  in  the  same  or  the  other  breast.  In 
four  cases  it  is  now  from  7  to  22  years  since  the  first  observation. 

Among  174  cases  of  simple  cysts  in  chronic  cystic  mastitis  14 
cases  gave  a  history  of  a  disappearing  tumor  before  they  came  under 
observation.  Among  fifty-nine  of  these  174  cases,  in  which  the  cystic 
tumor  only  was  removed,  six  have  observed  a  disappearing  tumor  since 
operation. 

Among  50  cases  of  chronic  cystic  mastitis  without  large  cysts  found 
at  operation  only  two  gave  a  history  of  a  disappearing  tumor. 

Apparently  the  disappearing  tumor  is  a  simple  cyst.  When  a 
simple  cyst  has  been  removed  from  the  breast  and  a  second  tumor  ap- 
pears later  in  this  or  in  the  other  breast,  there  is  great  probability 
that  this  is  another  cyst.  In  my  experience  it  has  been  cancer  in 
only  one  of  the  60  cases  when  both  breasts  were  saved,  and  one  out  of 
100  cases  when  one  breast  remained. 

Among  43  patients  whose  removed  tumor  proved  to  be  a  benign 
intracystic  papilloma  there  is  not  a  single  example  of  a  disappearing 
tumor  in  the  previous  history,  and  in  only  one  case  was  it  observed 
after  operation. 

Among  800  or  more  malignant  tumors  of  the  breast  we  have  recorded 
the  observation  of  a  disappearing  tumor  in  only  three  cases. 

The  history,  therefore,  of  a  disappearing  tumor  is  very  suggestive 
of  chronic  cystic  mastitis  with  cyst  formation.  But  I  would  not  allow 
this  to  influence  me  against  exploring  the  second  tumor  when  it  appears, 
because  there  is  a  possibility,  though  remote,  that  it  may  be  malignant. 

Multiple  Tiunors. — The  correct  presentation  oj  the  problem  here 
is  much  more  difficult  than  with  the  single  tumor.  The  number  of 
cases  is  relatively  small. 

The  most  significant  fact  is  that  among  the  cancers  of  the  breast 


LESIONS    OF   THE   FEMALE  BREAST  58 1 

the  majority  of  the  patients  presented  themselves  with  a  single  tumor 
in  one  breast. 

In  a  few  instances  there  were  multiple  tumors  in  one  or  both 
breasts.  These  observations  are  sufl&cient  to  show  that  one  of  multiple 
tumors  in  one  or  both  breasts  may  become  malignant. 

The  most  common  multiple  tumors  of  the  breast  are  those  which 
have  the  least  tendency  to  become  malignant — the  simple  cyst  and 
the  intracanalicular  myxoma. 

If  one  palpates  distinctly  more  than  one  tumor  in  a  breast,  or 
tumors  in  both  breasts,  at  least  one  tumor  in  each  breast  should  be 
explored.  One  should  select  the  tumor  of  longest  duration,  or  the 
largest,  or  the  one  most  suspicious,  on  palpation,  of  possible  malignancy. 
If  the  tumor  proves  to  be  a  simple  cyst,  or  an  intracanalicular  myxoma, 
or  a  lipoma,  I  think,  we  are  justified  in  removing  the  tumors  and  saving 
the  breast,  especially  in  younger  women.  We  have  a  number  of 
examples  of  the  removal  of  multiple  intracanalicular  myxomas  from 
one  or  both  breasts,  but  in  the  presence  of  multiple  simple  cysts,  the 
majority  of  surgeons  remove  the  entire  breast.  I  have  records  of  lo 
cases  only  in  which  multiple  simple  cysts  were  removed  from  one  or 
both  breasts.  These  patients  have  been  as  uniformly  relieved  as  the 
108  in  which  one  or  both  breasts  were  completely  excised. 

CLINICALLY  BENIGN  TUMORS 

When  the  surgeon  feels  unable  to  make  the  diagnosis  of  malignancy 
the  breast  lesion  for  practical  purposes*  is  clinically  benign  (Fig.  309). 
There  is  no  necessity  for  a  border-line  group  of  clinically  doubtful 
tumors,  because  to  one  who  knows  there  is  always  an  element  of 
uncertainty. 

Some  surgeons  from  their  experience  may  be  better  able  to  elicit 
slight  fixation  of  the  nipple,  atrophy  of  the  subcutaneous  fat,  dimpling 
or  slight  fixation  of  the  skin  (Fig.  310),  when  the  less  experienced  one 
might  overlook  these.  Again,  experience  is  helpful  in  the  interpretation 
of  the  palpation  of  the  tumor  and  the  surrounding  tissue. 

No  surgeon  should,  however,  feel  too  sure  of  his  clinical  diagnosis. 
If  there  are  definite  clinical  signs  largely  favoring  malignanc}',  the  opera- 
tion for  cancer  should  be  performed  without  an  exploratory  incision. 
The  number  of  mistakes  in  performing  this  for  a  benign  lesion  will  be 
relatively  very  small.  But,  on  the  other  hand,  if  all  the  signs  of  a 
malignant  tumor  are  absent,  it  is  not  justifiable  to  proceed  with  the 


582  REGIONAL   SURGERY 

complete  operation  for  cancer  without  excluding  a  benign  tumor  by  an 
exploratory  incision. 

The  per  cent,  of  benign  tumors  is  steadily  increasing,  in  my  observa- 
tion from  32  to  59  per  cent.,  and  if  every  woman  sought  advice  the 
moment  she  felt  a  lump  in  the  breast  the  proportion  of  benign  lesions 
would  be  still  greater. 

The  surgeon  today,  therefore,  must  prepare  himself  to  recognize 
breast  lesions  by  their  naked-eye  appearance,  with  or  without  the  aid 
of  a  frozen  section,  and  this  differential  diagnosis  is  more  difficult  than 
that  which  confronted  the  older  surgeons  in  the  clinical  differentiation. 
Then  women  waited  as  a  rule  until  each  lesion  had  differentiated 
itself.  Now  women  are  coming  when  there  is  no  known  clinical 
differentiation,  and  recently  the  number  of  cases,  in  which  there  is  a 
great  dilemma  at  the  exploratory  operation  and  in  the  frozen  section,  is 
increasing. 

Personally  I  have  seen  in  the  past  two  years  more  non-encapsulated 
zones  of  the  breast  tissue  which  at  first  sight  felt  and  looked  like  cancer 
at  the  exploratory  incision,  which  were  very  suspicious  of  cancer  in  the 
frozen  section,  but  which  I  believe  are  not  cancer. 

Until  recently  we  explored  10  per  cent,  of  lumps  which  turned  out 
to  be  cancer;  now  we  are  exploring  as  many  as  40  and  50  per  cent. 
According  to  my  records  the  mistakes  of  performing  the  complete  opera- 
tion for  cancer  for  a  benign  lesion  were  until  a  few  years  ago  about  10 
per  cent.  In  the  hands  of  the  same  group  of  surgeons  today  it  has 
reached  almost  15  per  cent. 

The  mistakes  are  not  made  with  scirrhus  or  medullary  cancer,  but 
with  local  areas  of  mastitis,  chronic  cystitis  mastitis,  papillomatous 
cysts,  and  adenomas.  All  of  these  benign  lesions  are  on  the  increase, 
while  the  fully  developed  medullary  and  schirrhous  carcinoma  are  on 
the  decrease. 

When  the  benign  lump  is  explored,  it  is  best  for  the  patient  to  treat 
the  lesion  as  malignant,  unless  one  is  absolutely  certain  that  it  is  benign. 
Mutilation  is  nothing  as  compared  with  the  fatality  of  an  incomplete 
operation  for  cancer. 

To  recapitulate:  When  the  palpable  lump  is  associated  with  re- 
traction of  the  nipple,  dimpling  or  adherent  skin,  or  a  pretty  definite 
infiltration  of  the  surrounding  breast,  that  is,  the  usual  signs  of  cancer, 
it  is  by  all  means  best  for  the  patient  to  perform  the  complete  operation 
for  cancer. 

When  at  the  exploratory  incision  the  naked-eye  appearance  and  the 


LESIONS    OF   THE   FEMALE   BREAST  583 

frozen  section,  leave  you  in  doubt  what  to  do,  the  complete  operation 
for  cancer  is  best  for  the  patient. 

One  should  not  mistake  medullary  or  scirrhous  carcinoma  for  any 
benign  lump. 

Until  a  few  years  ago  my  evidence  indicated  that  if  you  removed  a 
cancer  of  the  breast  as  the  original  lump  only  and  then,  later,  after 
microscopic  study,  performed  the  complete  operation  for  cancer,  the 
chances  of  a  cure  were  reduced  from  about  80  to  10  per  cent. 

However,  in  recent  years  a  large  number  of  border-line  tumors  have 
been  sent  to  the  laboratory  for  diagnosis — cases  in  which  the  tumor  only 
had  been  removed.  In  this  group  there  were  no  fully  developed  cancers. 
In  some  cases  the  laboratory  diagnosis  was  benign,  and  no  further  opera- 
tion was  advised.  In  others,  on  account  of  suspicion  it  was  advised  to 
remove  the  breast.  In  still  others  the  diagnosis  of  early  adenocarcinoma 
was  made,  and  the  complete  operation  for  cancer  was  suggested. 

The  remarkable  fact  about  this  group  is  that  in  spite  of  what  diag- 
nosis we  made  and  what  operation  we  advised,  there  is  not  a  single 
death  from  cancer,  nor  a  single  recurrence. 

This  group  of  about  sixty  cases  has  been  submitted  to  many  patholo- 
gists throughout  the  country.  In  not  a  single  case  is  there  a  uniform 
agreement  as  to  the  diagnosis,  or  what  should  have  been  done. 

For  example,  some  of  the  encapsulated  tumors  which  we  had  con- 
sidered benign  cystic  adenomas  or  fibroadenomas,  other  pathologists 
have  diagnosed  cancer.  In  this  group  of  cases  the  tumors  only  were 
removed.  On  the  other  hand,  in  cases  which  were  considered  by  us 
early  adenocarcinoma  and  in  which  we  adxised  the  complete  operation 
for  cancer,  the  consulting  pathologists  have  viewed  the  breast  lesion 
as  benign. 

This  introduction  is  absolutely  essential  to  what  follows. 

The  diagnoses  are  my  own,  but  it  is  important  for  the  reader  to 
know  that  in  the  border-line  group  there  are  some  pathologists  who 
agree,  and  some  who  disagree,  with  the  diagnoses  made.  The  thing  to 
bear  in  mind  with  great  emphasis  is,  that  no  patient  has  suffered  from 
this  disagreement,  except  now  and  then  from  an  unnecessary  removal  of 
the  breast. 

What  I  wish  to  emphasize  also  is,  that  the  operation  for  these  border- 
line tumors  in  two  stages  yields  just  as  good  results  as  in  one  stage,  and 
apparently  it  has  been  the  results  in  cases  of  this  kind  in  the  past  that 
have  impressed  surgeons  that  it  was  not  dangerous  to  operate  for  cancer 
of  the  breast  in  two  stages.     It  is  apparently  just  as  dangerous  today 


584  REGIONAL    SURGERY 

to  operate  for  fully  developed  cancer  in  two  stages,  but  it  is  not  danger- 
ous to  operate  for  a  benign  or  precancerous  lesion  in  two  stages.  In 
fact,  it  must  be  remembered  that  in  many  of  these  latter  cases  the 
second  operation  was  unnecessary.  I  am  confident,  however,  that  the 
complete  removal  of  the  breast  is  a  definite  protective  procedure  in 
certain  non-encapsulated  lesions  of  the  breast  which  may  be  included 
under  the  terms  chronic  mastitis  and  chronic  cystic  mastitis. 

CYSTIC  AND  SOLID  TUMORS  OF  THE  BREAST 

The  simple  cyst  (Fig.  311)  is  characterized  by  a  distinct  blue  dome, 
smooth  wall  and  non-hemorrhagic  contents;  the  papillomatous  cyst 
(Fig,  321)  by  the  intracystic  papilloma;  the  galactocele  (Fig.  302)  by 
its  milky  contents  and  smooth  wall.  The  chronic  pyogenic  abscess 
(Fig.  303)  contains  cloudy  material  and  has  a  wall  which  looks  like 
granulation  tissue.  The  tuberculous  abscess  (Fig.  304)  contains  the 
usual  pus  and  pretty  characteristic  granulation  tissue  in  the  wall. 

In  contrast  to  these  benign  cysts,  the  malignant  cyst  (Fig.  305), 
whether  cancer  or  sarcoma,  has  hemorrhagic  contents  without  papilloma, 
or  a  thick  grumous  material  entirely  different  from  the  contents  of  a 
pyogenic  or  tuberculous  abscess,  and  some  thick  area  in  its  wall  which 
an  expert  surgeon  could  select  for  frozen  section. 

The  solid  tumors  of  the  breast  must  be  divided  into  those  en- 
capsulated, circumscribed,  and  infiltrating. 

In  my  experience  distinct  encapsulation  is  a  sign  of  a  benign 
tumor,  usually  some  form  of  an  adenoma — cystic,  fibrous  or  intra- 
canalicular.  In  these  cases  one  is  helped  most  by  the  gross  appearance. 
The  histological  picture  of  the  intracanalicular  myxoma  is  the  least 
confusing;  that  of  the  cystic  and  fibrous  adenoma  is  frequently  inter- 
preted as  doubtful  or  malignant,  when  the  microscopic  appearance 
only  has  been  considered. 

Medullary  carcinoma,  scirrhus,  adenocarcinoma  and  sarcoma  may 
be  circumscribed.  The  gross  and  frozen-section  appearance  of  all 
but  adenocarcinoma  is  so  distinct  that  no  surgeon  should  today  ever 
make  the  mistake  of  performing  an  incomplete  operation  for  these 
forms  of  cancer  of  the  breast.  When,  however,  certain  benign  lesions 
resemble  these  more  malignant  forms  in  the  gross  appearance  or 
frozen  section,  the  mistake  of  the  complete  operation  will  have  to  be 
made. 

Certain  types  of  adenocarcinoma  are  easy  to  recognize:   The  colloid 


LESIONS   OF  THE   FEMALE  BREAST 


585 


from  its  intercellular  substance,  and  the  duct  cancer  (comedo  adeno- 
carcinoma) from  the  characteristic  worm-like  tubules  which  can 
be  expressed  from  the  cut  surface. 

The  type  of  adenocarcinoma  difl&cult  to  recognize  is  that  closely 
associated  with  cystic  adenoma,  a  more  or  less  circumscribed  tumor, 
and  chronic  cystic  mastitis,  a  diffuse  lesion. 

The  diffuse  benign  lesions  of  the  breast  are  most  difficult  of  all. 
We  have,  first,  during  lactation  the  chronic  mastitis  with  no  large  areas 


Fig.  311 . — Photograph  of  simple  cyst  surrounded  by  a  zone  of  breast.  Note  the  distinct 
cyst  wall,  smooth  surface,  one  dilated  duct  and  many  adenomatous  areas  of  surrounding 
breast. 

Path.  No.  19040. — White,  female,  aged  38.  Tumor  and  pain  three  weeks.  Opera- 
tion, 1910.  Excision  of  cyst  and  zone  of  breast.  1916,  six  years,  well.  This  photograph 
illustrates  how  a  simple  cyst  should  be  excised  after  it  is  e.xplored. 


of  pus  formation.  Then,  in  the  non-lactating  breast  difi'erent  forms  of 
chronic  cystic  mastitis  and  chronic  mastitis  without  cyst  formation. 

I  shall  attempt  to  present  one  or  more  illustrations  of  the  different 
groups. 

At  this  time  I  again  wish  to  make  the  emphatic  statement  that 
in  the  great  majority  of  cases  a  decision  as  to  what  is  best  for  the  patient 
can  be  more  readily  made  from  the  gross  appearance.     Frozen  sections 


586  REGIONAL   SURGERY 

can  be  made.     We  need  some  differential  staining  method  for  more 
exact  diagnosis. 

CYSTIC  TUMORS 

Simple  Cysts. — Usually  on  palpation  the  tumor  is  spherical  and 
tense  (Fig.  309)  and  suggests  a  cyst,  but  in  some  cases  when  it  is  buried 
in  breast  tissue  one  palpates  the  mass  of  breast  tissue  containing  the 
cyst,  and  the  area  feels  more  like  a  cancer  than  a  cyst. 

When  explored  carefully,  the  thin  cyst  wall  appears  as  a  blue  dome. 
One  may  pass  through  skin  and  fat  only,  before  the  cyst  wall  is  reached. 


Fig.  312. — Adenomatous    areas   in  zone  of  breast  removed  with  a  simple  cyst.     Some 

areas  show  beginning  ectasia. 

Path.  No.  16133. — White,  female,  aged  45;  tumor  and  pain  12  days.     Excision  of  cyst 

and  zone  of  breast.     19 16,  well  two  years. 

or  also  through  a  zone  of  breast  tissue.  The  moment  the  thin  wall  is 
nicked  the  color  disappears.  The  lining  of  the  cyst  is  always  smooth ; 
the  contents  clear  or  cloudy;  never  hemorrhagic,  nor  grumous,  thick 
material. 

The  cyst  wall  (Fig.  3 1 1 )  is  usually  thin ;  but  even  when  slightly  thicker, 
it  is  sharply  demarkated  from  the  breast  tissue.  When  this  cyst  is 
cut  out  with  a  zone  of  breast,  one  may  encounter  dilated  ducts  filled 
with  green,  gray  or  yellow  grumous  pastille  material,  other  cysts  of 
different  sizes,  and,  scattered  in  the  white  opaque  breast  tissue,  one 


587 


Fig.  313. — Irregular  adenomatous  areas  and  dilated  duct  in  breast  containing  multiple 

cysts  and  early  chronic  cystic  mastitis. 
Pathol.  No.  16786. — White,  female,  aged  45;  pain  five  days,  tumor  four  days.     1915,  ex- 
cision of  zone  of  breast  containing  a  few  small  cysts.     19 16,  one  year,  well. 


Fig.   314. — Area  of  chronic  mastitis  in  breast  near  wall  of  simple  cyst. 

Pathol.  No.  8717. — White,  female,  aged  45;  tumor  five  weeks,  one  week  after  trauma. 

1908,  complete  excision  of  breast  because  of  multiple  cysts.     1916,  eight  years,  well. 


588 


REGIONAL   SURGERY 


Fig.  315. — Area  of  ectasia  in  breast  containing  multiple  cysts  and  dilated  ducts. 

Pathol.  No.  9394. — White,  female,  aged  67;  tumor  and  pain  six  weeks.  Nipple^  re- 
tracted; only  one  tumor  palpable.  1908,  complete  operation  for  cancer  based  on  retracted 
nipple.     Breast  contained  three  simple  cysts.     1916,  eight  years,  well. 


Fig.  316. — Epithelium-lined  minute  cyst  in  breast  containing  multiple  cysts  and^dilated 

ducts. 
Pathol.  No.  9394. — For  history  see  Fig.  315. 


LESIONS    OF   THE    FEMALE   BREAST 


589 


Fig.  317. — Adenocystic  areas  in  breast  containing  multiple  cysts  and  dilated  ducts. 
Pathol.  No.  9394. — For  history  see  Fig.  315. 


Fig.  318. — Dilated  ducts,  lined  with   basal  cells,  tilled  with  gruraous  material.     Breast 

the  seat  of  multiple  cysts  and  dilated  ducts. 

Pathol.  No.  8717. — For  clinical  history  see  Fig.  314. 


590 


REGIONAL   SURGERY 


Fig.  319. — Area  of  duct  adenoma  in  zone  of  breast  about  a  simple  cyst. 

Pathol.  No.  14095. — White,  female,  aged  37;  pain  three  months,  tumor  one  month.    1913, 

excision  of  cyst  and  zone  of  breast.     19 16,  well. 


Fig.  320. — Area  of  duct  papilloma  in  chronic  mastitis  in  breast  about  a  simple  cyst. 

Pathol.  No.  16133. — White,  female,  aged  45;  tumor  and  pain  12  days.  1914,  excision  of 
cyst  in  zone  of  breast.     1916,  well. 

This  patient's  left  breast  had  been  removed  seven  years  before  apparently  for  a  simple 
cyst. 


LESIONS    OF   THE    FEMALE  BREAST  59 1 

may  see  the  pink  elevated  dots  of  the  adenomatous  hypertrophy 
which  is  apparently  the  first  stage  of  the  chronic  cystic  mastitis.  The 
practical  point,  however,  is  that  in  an  experience  with  178  cases  there 
is  little  or  no  relation  between  this  cyst  and  cancer,  and  in  the  great 
majority  of  cases  the  breast  can  be  saved. 

However,  when  microscopic  sections  are  made  of  the  wall,  we  may 
find  all  stages  of  chronic  cystic  mastitis  (Figs.  312  to  320)  and  areas 
which,  if  we  did  not  know  the  gross  pathology,  might  be  considered 
sufl&ciently  suspicious  to  justify  the  removal  of  the  breast. 

It  is  frozen  sections  from  the  breast  about  these  blue-domed  cysts 
which  give  cellular  pathologists  their  dilemmas. 

Papillomatous  Cysts. — The  majority  of  surgeons  fear  to  do  a 
conservative  operation  for  a  cyst  with  a  papilloma,  especially  when 
it  contains  blood.  However,  if  these  papillomatous  cysts  are  sub- 
jected to  operation  in  the  early  benign  stage,  there  is  absolutely  no 
necessity  for  the  removal  of  the  breast.  The  cyst  is  not  blue-domed 
as  is  the  simple  cyst.  When  opened  it  usually  contains  blood-stained 
serum.  The  papillomata  may  be  of  various  sizes,  partially  or  com- 
pletely filling  the  cyst,  but  the  surface  is  always  papillomatous.  This 
is  lost  in  the  malignant  papilloma.  When  excising  the  benign  papil- 
lomatous cyst,  study  the  breast  tissue.  If  other  papillomatous  cysts 
are  encountered,  or  if  there  are  a  number  of  dilated  ducts  and  small 
cysts,  remove  the  breast,  a  procedure  which  is  not  followed  in  the  benign 
blue-domed  cyst.  If  the  breast  tissue  is  normal,  remove  the  cyst  only. 
Fig.  321  pictures  a  papillomatous  cyst  with  a  zone  of  breast  removed 
with  it.  After  one  has  removed  the  cyst,  its  wall  with  the  base  of  the 
papilloma  should  be  studied.  If  beneath  the  papilloma  there  is  no 
distinct  wall,  but  an  invasion  of  the  breast  by  the  papilloma,  im- 
mediately perform  the  operation  for  cancer. 

In  some  cases  of  papillomatous  cysts  thus  conservatively  treated 
many  pathologists  have  diagnosed  the  microscopic  section  cancer.  In 
the  case  represented  in  Fig.  322  there  has  been  no  recurrence  19  years 
after  the  excision  of  the  papillomatous  cyst  only. 

At  the  present  time  a  large  per  cent,  of  papillomatous  cysts  are 
treated  by  the  removal  of  the  breast,  or  the  complete  operation  for 
cancer.  Especially  now  that  women  are  coming  earlier  with  the 
lump,  this  mutilating  operation  should  be  performed  less,  and  without 
any  added  risk  to  the  patient. 

Galactocele,  a  cystic  tumor  due  to  the  accumulation  of  milk  in  a 
dilated  duct.     Clinically  I  have  never  been  able  to  make  out  the  bottle- 


592 


REGIONAL    SURGERY 


shaped  form  mentioned  in  the  literature.  To  have  a  true  galactocele 
there  must  be,  or  have  been,  lactation.  My  observations  show  that 
lactation  hypertrophy  may  persist  in  the  breast  14  years  after  nursing 
the  last  child  (Fig.  323).     Apparently  the  cause  of  this  is  some  local 


Fig.  321. — Benign  papillomatous  cyst  in  a  senile  and  fibrous  breast;  some  dilated  ducts 

and  chronic  cystic  mastitis. 
Pathol.  No.  17514. — White,  female,  aged  66;  tumor  after  trauma  eight  months;  no  dis- 
charge from  nipple.      On  account  of  the  slight  infiltration  of  the  skin  (probably  the  result  of 
the  traumaj  complete  operation  for  cancer  (1915).     1916,  one  year,  well. 

irritation,  such  as  a  galactocele,  a  benign  tumor,  or  a  chronic  mastitis. 
As  long  as  there  is  lactation  hypertrophy  in  the  breast  and  a  plugged 
duct,  galactocele  is  possible. 

In   the   20  years  previous  to  19 10  we  observed  but  two  galacto- 
celes,  since  1910  twelve.     In  the  past,  therefore,  we  have  either  over- 


LESIONS    OF   THE    FEMALE   BREAST 


593 


Fig.  322. — Benign  papillomatous  cyst.     Section  from  papilloma. 
Pathol.  No.  1596. — Operation  in  1896,  excision  of  cyst  and  zone  of  breast. 
White,  female,  aged  45;  discharge  of  blood  from  nipple  15  years;  tumor  10  years.     1915, 
19  years,  well. 

This  section  has  been  considered  by  many  pathologists  as  carcinoma. 


Fig.  323. — Area  of  residual  lactation  hypertrophy  and  dilated  ducts. 
Pathol.  No.  5088. — This  breast  was  also  the  seat  of  a  medullary  carcinoma. 
38 


594 


REGIONAL    SURGERY 


looked  galactoceles,  or,  on  account  of  delay,  the  patient  has  come 
under  observation  with  cancer.  As  a  rule  with  the  galactocele  the 
breast  is  the  seat  of  mastitis  or  areas  of  lactation,  or  there  may  be  multi- 
ple galactoceles  (Fig.  324).  In  the  majority  of  cases  the  condition  is 
mistaken  clinically,  at  the  exploratory  incision,  or  even  in  the  frozen 
section,  and  treated  as  malignant.  There  is  nothing  of  special  difficulty 
in  recognizing  the  galactocele  with  its  smooth  wall  and  milky  contents. 
But  when  the  breast  is  the  seat  of  mastitis,  areas  of  lactation  hyper- 
trophy, and  dilated  ducts  filled  with  creamy  material,  we  have  a  con- 


FiG.  324. — Multiple  galactoceles  and  dilated  ducts. 
Pathol.  No.  8166. — 1907,  excision  of  breast.  White,  female,  aged  34;  history  of  abscess 
in  this  breast  some  years  ago.  The  patient  is  nursing  her  child  aged  20  months.  Latca- 
tion  in  the  affected  breast,  scanty.  Lump  observed,  six  months.  In  addition  to  tumor 
multiple  nodules  in  breast.  After  operation,  cream-like  material  could  be  expressed  from 
the  dilated  ducts. 


fusing  picture,  and  the  probabilities  are  that  the  majority  of  surgeons 
will  do  the  complete  operation  for  cancer — the  safer  procedure.  It  is 
quite  possible  that  if  we  see  the  galactocele  quickly  as  was  my  good 
fortune  in  the  last  two  cases  of  two  and  five  weeks'  duration,  there  will 
be  but  a  single  palpable  tumor,  and  the  typical  cyst  will  be  recognized  on 
exploration.  Fig.  302  pictures  a  galactocele  in  which  the  condition  was 
treated  on  the  diagnosis  of  cancer.  Fig.  324  shows  the  diffuse  disease  of 
the  breast  — dilatation  of  all  the  ducts  often  associated  with  galactocele. 
Chronic  Lactation  Mastitis  Abscess. — This  disease  may  appear  as 
a  single  tumor,  and  at  exploration  as  a  single  cyst  (chronic  abscess)  in 


LESIONS    OF    THE    FEMALE   BREAST 


595 


an  apparently  normal  lactating  breast.  The  contents  of  the  chronic 
mastitis  abscess  is  somewhat  purulent,  but  never  hemorrhagic  or 
grumous,  as  in  the  cancer  cyst.  Nevertheless  its  thick  wall  may  give 
rise  to  suspicion  of  cancer.  The  frozen  section  (Fig.  303)  is  to  many 
pathologists  even  more  confusing.  The  disease  should  be  distinguished 
from  cancer  in  the  gross.  When  the  breast  is  the  seat  of  chronic  mastitis 
with  remaining  areas  of  lactation  hypertrophy,  we  have  a  clinical, 
gross  and  microscopic  picture  so  difficult  to  recognize  with  certainty, 
that  I  would  advise  the  complete  operation  for  cancer.     There  is  little 


Fig.  325. — Adenocystic  changes  in  tubercular  mastitis,  suggesting  early  carcinoma. 

Pathol.  No.  3170. — Complete  operation  for  cancer  in  1900.  White,  female,  aged  35;  pain 
three  months;  tumor  two  months;  sinus  one  month. 

Ten  years  later  the  patient  was  under  observation  with  tubercular  peritonitis.  No 
evidence  of  cancer. 


to  lose,  as  in  the  majority  of  these  cases  the  breast  must  be  sacrificed  in 
any  event. 

Tuberculous  Abscess. — We  are  rarely  given  the  opportunity  to  see 
a  tuberculous  abscess  of  the  breast  before  it  is  ruptured.  Tuberculosis 
of  the  breast  is  usually  a  single  focus  and  appears  first  as  an  area  of 
induration.  Softening  with  abscess  formation  takes  place,  as  a  rule, 
before  six  months  and  a  sinus  forms.  The  tuberculous  abscess  (Fig. 
304)  of  the  breast  does  not  differ  in  the  gross  from  the  same  lesion  any- 
where else.     However,  microscopically,  in  the  wall  of  the  cavity  the 


596 


REGIONAL    SURGERY 


mastitis  secondary  to  the  tuberculosis  is  frequently  looked  upon  as 
adenocarcinoma  (Fig.  325).  I  have  never  been  able  to  conclusively 
prove  the  presence  of  cancer  in  any  tuberculous  abscess  of  the  breast, 
although  many  of  these  cases  had  been  diagnosed  and  treated  as  cancer. 
In  none  have  the  glands  shown  metastasis,  nor  have  any  of  the  patients 
died  of  cancer. 

Cancer  Cysts. — A  smooth-walled  cyst  with  bloody  contents  and 
without  a  papilloma  should  be  treated  as  cancer.  A  smooth-walled 
cyst  with  thick  grumous  material  is  always  malignant.     In  the  majority 


Fig.  326. — Typical  fully  developed  cancer  in  wall  of  cancer  cyst. 
Pathol.  No.  5252. — Operation  in  1904,  complete  for  cancer. 
White,  female,  aged  64;  pain  three  months;  tumor  two  months. 

of  cases  cancer  can  be  recognized  in  the  wall  of  these  cysts  at  the 
exploratory  incision. 

In  the  past  smooth-walled  cysts  containing  blood  were  the  cancer 
cysts  not  recognized  by  the  surgeons,  and  treated  as  benign. 

Figure  305  shows  a  somewhat  smooth-walled  cancer  cyst  which 
contained  blood. 

In  the  20  cases  of  cancer  cysts  observed  by  me,  fully  developed  car- 
cinoma or  sarcoma  was  readily  recognized  in  the  microscopic  section 
(Fig.  326). 


LESIONS    OF   THE   FEMALE   BREAST 


597 


In  the  differential  diagnosis  of  the  different  types  of  cysts  one  is 
helped  most  by  the  contents  of  the  cyst,  by  the  character  of  the  wall, 
by  the  appearance  of  the  papilloma,  if  present,  and  by  the  careful  study 
of  the  base  of  the  papilloma.  There  should  really  be  little  difficulty 
in  recognizing  the  cancer  cyst,  but  when  the  benign  cyst  is  associated 
with  some  diffuse  disease  of  the  breast,  such  as  lactation  mastitis, 
chronic  cystic  mastitis,  multiple  galactoceles,  the  surgeon  is  usually 
confused  and  the  complete  operation  for  cancer  performed. 

SOLID  ENCAPSULATED  TUMORS 

The  benign  solid  encapsulated  tumors  are  cystic  adenoma,  intra- 
canalicular  myxoma  and  fibroadenoma.     The  common  characteristic 


Fig.  327. — Encapsulated  cystic  adenoma  removed  with  a  zone  of  breast. 
Pathol.  No.  2568. — Operation  in  1899.     White,  female,  aged  30;  tumor  10  years. 

which  differentiates  them  from  the  malignant  tumors  is  the  presence 
of  a  distinct  capsule.  One  could  enucleate  them  from  the  surrounding 
breast.  Often,  however,  at  one  point  the  capsule  is  less,  distinct 
and  there  is  the  appearance  of  an  isthmus-like  connection  between 
the  tumor  and  the  breast.  I  have  never  observed  a  malignant  tumor 
with  such  a  capsule. 

In  the  cystic  adeiio?na  (Figs.  327  and  3  28)  one  sees  minute  cysts  through- 
out the  tumor.  Some  are  filled  with  clear  or  cloudy  fluid,  others  seem 
to  contain  a  granular  material  which,  as  a  rule,  does  not  express  on 
pressure.  Microscopically,  on  account  of  the  large  number  of  pictures 
met  with,  these  tumors  are  often  diagnosed  early  carcinoma,  and 
breasts  are  unnecessarily  sacrificed.  About  30  per  cent,  of  pathologists 
diagnosed  the  section  (shown  in  Fig.  329)  cancer.     In  this  case  for- 


598 


REGIONAL    SURGERY 


tunately  only  the  tumor  had  been  removed.     There  has  been  no  local 
recurrence  now  four  years  since  operation. 

The  fibroadenoma  shows  no  minute  cysts.  It  may  be  marked  by 
little  crevices  or  show  minute  dots,  and  in  addition  there  are  white 
and  gray  areas  (Fig.  306).  In  some  fibroadenomas  there  is  so  little 
stroma  (Fig.  330)  that  they  almost  resemble  a  miniature  pancreas. 
But  here  again  pathologists  have  been  found  to  disagree  in  the  micro- 
scopic study  (Fig.  331).  Here  the  diagnosis  of  malignancy  is  as  five 
to  two  benign. 


Fig.  328. — The  microscopic  picture  of  cystic  adenoma  and  chronic  cystic  mastitis. 

Pathol.  No.  9394. — For  clinical  history  see  legend  of  Fig.  315.    Tl;e  different  tj^esof  areas 

in  this  zone  of  breast  are  designated  in  Figs.  315,  316  and  317. 

When  these  fibroadenomas  are  present  in  the  lactating  breast, 
they  undergo  lactation  hypertrophy  (Fig.  307),  and  here  the  frozen- 
section  diagnosis,  when  one  is  not  familiar  with  lactation,  is  very 
confusing. 

The  fibroadenoma  situated  within  the  breast  rarely  reaches  great 
size  (a  characteristic  of  the  intracanalicular  myxoma).  When  present 
for  a  number  of  years  the  fibroadenoma  may  become  calcified. 

Aberrant  Fibroadenomas. — The  most  frequent  tumor  observed  out- 
side of  the  breast  resembles  the  fibroadenoma.  It  may  often  attain 
a  size  larger  than  that  of  the  breast  (Fig.  301)  and  many  of  these  cases 
are  treated  on  the  diagnosis  of  sarcoma.     The  tumor,  ho-^ver,  is 


LESIONS    OF   THE    FEMALE   BREAST 


599 


always  encapsulated.  Its  gross  appearance  is  typically  glandular 
(Fig.  332),  and  microscopically  it  differs  from  breast  tissue  at  puberty 
only  in  the  irregularity  of  the  arrangement  of  parenchyma  and  stroma 
(Fig.  333)- 


Fig.  329. — Cystic  adenoma. 

Pathol.  No.  13599. — Operation  in  1912,  excision  of  tumor  and  zone  of  breast.  1916, 
four  years,  well. 

White,  female,  aged  22;  tumor  three  months.  Consulting  pathologists  differ  as  to 
diagnosis. 

Intracanalicular  Myxoma. — The  small  intracanalicular  myxoma 
does  not  differ  much,  in  the  gross,  from  the  adenofibroma  (Fig.  334). 
In  a  few  instances  the  tumor  looks  so  succulent  that  it  gives  one  the 
impression  of  a  medullary  carcinoma.  Here  a  frozen  section  will  be 
most  helpful,  because  there  is  nothing  more  characteristic  than  its 
histology  (Fig.  335). 


6oo 


REGIONAL   SURGERY 


I  have  been  told  about,  but  have  never  seen,  a  perfectly  encapsulated 
medullary  carcinoma.  If  there  be  such  a  thing,  the  frozen  section 
will  immediately  differentiate  it.     As  the  intracanalicular  myxoma 


Fig.  330. — Small  encapsulated  fibroadenoma,  excised  with  a  zone  of  breast;  stroma, 

scanty. 
Pathol.  No.  19063. — White,  female,  aged  40;  tumor  a  few  months.     Operation  in  1916 
excision  of  tumor  with  zone  of  breast. 

For  microscopic  appearance  see  Fig.  333. 


Fig.  331. — Fibroadenoma.  Consulting  pathologists  differ  as  to  diagnosis.  The  tumor 
was  a  small,  distinctly  encapsulated  area  in  the  breast  of  a  young  girl  under  twenty-five. 
Pathol.  No.  19060. — Excision  of  tumor  only. 


grows  larger,  its  peculiar  gross  appearance  becomes  more  characteristic. 
In  this  middle  stage  it  has  neither  the  cysts  of  the  cystic  adenoma, 
nor  the  splits  of  the  adenofibroma,  but  rather  the  appearance  of  the 
hypertrophied  prostate. 


LESIONS  OF  THE  FEMALE  BREAST  6oi 

The  gross  appearance  of  the  large  intracanalicular  myxoma  may 
be  variegated  (Fig.  336),  but  there  is  no  necessity  for  any  attempt  at 
diagnosis  before  operation:  These  large,  apparently  encapsulated 
tumors  occupying  more  than  one-fourth  of  the  breast  should  be  treated 
as  sarcoma — the  tumor,  breast,  an  area  of  skin  and  the  greater  pectoral 
muscle  should  be  removed. 


Fig.  332. — Encapsulated,  large,  aberrant  fibroadenoma,  incorrectly  diagnosed  sarcoma. 
Pathol.  No.  6060. — Operation  in  1Q04,  complete  for  sarcoma.     Colored,  girl,  aged  17; 
small  tumor  observed  shortly  after  birth;  rapid  growth  since  puberty  for  three  years. 
1916,  twelve  years,  well. 

These  three  adenomas  of  the  breast  should  offer  but  little  diagnostic 
difficulty  at  the  exploratory  incision.  The  chief  characteristic  is 
encapsulation. 

Malignant  tumors  may  be  circumscribed,  but  they  can  never  be 
enucleated  from  the  surrounding  breast  tissue,  and  when  one  explores 
a  solid  tumor  which  is  not  encapsulated,  one  should  treat  such  a 
tumor  as  malignant. 

Until  recently  all  the  distinct  solid  tumors  which  were  not  en- 


6o2 


REGIONAL   SURGERY 


capsulated  and  which  were  explored  by  me  were  malignant.     Now  that 
I  am  seeing  cases  earlier  I  have  met  with  a  number  that  are  benign. 

Circumscribed,  but  not  Encapsulated  Benign  Tumors. — Figure  337 
represents  such  a  tumor  which  I  explored  in  191 5.  There  was  no 
capsule,  it  felt  to  the  finger  like  cancer,  and  gave  the  gritty  sensation 


Fig.  333. — Microscopic  picture  of  the  usual  aberrant  fibroadenoma.      For  gross  ap- 
pearance and  history  see  Fig.  330. 


of  a  scirrhus  under  the  knife.  This  lump  had  been  in  the  breast 
perhaps  20  years,  but  in  the  last  few  weeks  had  seemed  to  grow 
and  had  become  painful.  The  microscopic  appearance  is  shown  ir 
Fig.  338. 

We   may   also   observe   circumscribed   areas   of   chronic   mastitis, 
chronic   cystic   mastitis,   cystic   adenoma   and   fibroadenomas   which 


LESIONS    OF   THE    FEMALE   BREAST 


603 


have  lost  their  capsule.  Now  that  women  as  seeking  advice  earlier 
after  the  first  appearance  of  the  tumor,  or  more  quickly  after  the 
first  change  in  an  old  tumor,  this  new  group,  most  difticult  to  diagnose, 


Fig.  334.— Encapsulated  intracanalicular  myxoma. 
Pathol.  No.  18374. — Operation  in  1915,  excision  of  tumor  and  zone  of  breast. 

will  increase.     So  far  all  the  cases  recorded  by  me  have  been  treated 
on  the  diagnosis  of  early  cancer. 

Chronic  Cystic  Mastitis. — This   disease   may  appear  as   a  blue- 
domed  simple  cyst  (Fig.  311)  such  as  I  have  described.     Apparently 


Fig.  335. — Microscopic  appearance  of  intracanalicular  myxoma. 
Pathol.  No.  2761. 

this  is  by  far  the  most  common  condition.  Chronic  cystic  mastitis  is 
probably  present  in  many  breasts,  but  not.  until  a  cyst  forms  is  the 
patient  aware  of  it.     Previous    to    the   formation    of  the  cyst  these 


6o4  REGIONAL    SURGERY 

patients  may  experience  pain.  At  the  present  time  we  are  seeing 
many  women  with  painful  breasts,  more  than  ever  before.  ■  Again, 
we  are  seeing  a  number  of  cases  of  painful  breasts  in  which  on  ex- 
amination we  find  one  or  more  nodules  in  one  or  both  breasts.     True, 


^^^^^^^^^^^^P^^^^^I^HHpR^^^^^^^^^^^^^^^^^^^^H 

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^^1 

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Fig.  336. — Large  encapsulated  intracanalicular  myxoma,  which  usually  shows  sar- 
comatous changes  and  should  be  treated  as  sarcoma. 
Pathol.  No.  17970- — Operation  in  1915,  excision  of  tumor  only,  later  on  advice  from 
Pathological  Laboratory,  complete  excision  of  scar  and  pectoralis  major  muscle. 
White,  female,  aged  39,  tumor,  two  years.     1916,  one  year,  well. 

the  nodules  are  rather  indefinite  to  the  experienced,  but  are  often 
considered  tumors  by  the  patient  and  inexperienced  physician  or 
surgeon.  When  we  feel  a  definite  tumor,  explore  it,  and  find  the  blue- 
domed,  smooth- walled  cyst  (Fig.  311)  we  have,  as  I  have  stated  before 
and  wish  to  repeat  here  again,  clinical  and  gross  evidence  of  a  benign 


LESIONS   OF  THE   FEMALE   BREAST  605 

lesion.  As  we  cut  out  these  simple  cysts  or  when  we  examine  the  re- 
moved breast,  we  always  find  evidence  of  a  diffuse  disease  of  the 
breast:     There  are  minute  cysts  of  various  sizes,  dilated  ducts  filled 


Fig.  337. — Circumscribed,  but  not  encapsulated  cystic  adenoma.     Gross  appearance  at 
exploratory  incision  suggested  cancer. 
Pathol.  No.  17012. — Operation  in  1915,  exploration  followed  by  complete  operation  for 
cancer.     White,  female,  aged  30;  little  tumor  20  years;  recent  growth  and  pain  two  weeks 
For  microscopic  appearance  see  Fig.  338. 

with  grumous  material;  pink,  elevated  dots.  These  may  be  scattered 
in'  the  breast  tissue,  rather  diffusely  mixed  with  the  fibrous  stroma. 
In  cases  of  this  kind  they  make  little  impression  upon  the  ordinary 


Fig.  338. — Cystic  adenoma.     For  gross  and  clinical  note  see  Fig.  317 
Compare  this  section  with  Figs.  328,  329,  and  319. 

observer.  However,  we  may  meet  the  disease  as  a  circumscribed  area 
when  it  has  the  exact  appearance  of  a  cystic"  adenoma,  except  that  it 
is  not  encapsulated.     A  quadrant  or  a  hemisphere,  or  the  entire  breast 


6o6 


REGIONAL    SURGERY 


may  be  involved  in  this  parench3^matous  change  (Fig.  339).  It  has 
received  many  names — SchimmelhuscJi' s  or  Rectus^  disease,  abnormal 
involution,  senile  parenchymatous  hypertrophy.  I  prefer  to  return  to 
the  old  terminology  of  Billroth — chronic  cystic  mastitis.  This  patho- 
logical process  impresses  me  as  a  reaction  to  some  irritant.  Micro- 
scopically and  in  addition  to  the  parenchymatous  changes,  there  is 
evidence  of  reaction  in  the  stroma  of  the  breast.  No  relation  between 
this  disease  and  any  microorganism  has  yet  been  established. 

In  a  smaller  group  of  cases  there  are  no  large  simple  cysts  (Fig.  339). 
In  this  group  before  operation  we  may  palpate  an  indistinct  tumor, 
a  distinct  circumscribed  area,  or  a  diffuse  shot-like  mass  involving  a 
quadrant,  a  hemisphere  or  the  entire  breast. 


Fig.  339. — Chronic  cystic  mastitis;  no  large  cysts.  N  =  normal  breast;  C  =  minute 
cysts;  X  —  areas  suspicious  of  adenocarcinoma;  Ad  =  adenocystic  areas. 
Pathol.  No.  3965. — Operation  in  1901,  complete  excision  of  breast.  1916,  15  years, 
well.  White,  female,  aged  40;  pain  six  months,  nodular  enlargement  of  one  quadrant  four 
months.  Slight  discharge  from  nipple.  After  microscopic  study  of  this  breast  the  complete 
operation  was  advised,  but  refused  by  patient.  For  microscopic  appearance  see  Figs.  312 
to  320  and  Figs.  328,  329  and  331. 


When  we  study  these  areas  microscopically  we  find  a  great  variety 
of  histological  pictures,  difficult  to  interpret. 

Until  three  years  ago  about  50  per  cent,  of  the  cases  of  chronic  cystic 
mastitis  without  large  cysts  were  looked  upon  as  malignant,  in  the  past 
three  years  only  30  per  cent. 

As  we  have  no  exact  method  of  differentiating  the  benign  from  the 
malignant,  I  am  convinced  that  it  is  safer  in  these  cases  to  radically 
remove  the  entire  breast  with  the  pectoral  fascia.  If  there  is  any 
evidence  of  cancer,  operate  as  you  would  for  cancer. 

The  time  may  come  when  we  will  be  able  to  differentiate,  but  at 
the  present  time  I  am  convinced  that  this  is  the  safest  procedure. 

It  seems  strange  that  in  the  larger  group,  when  we  find  a  definite 


LESIONS    OF   THE    FEMALE   BREAST  607 

smooth-walled  cyst,  experience  shows  that  it  is  justifiable  to  perform 
the  conservative  operation  of  excision  of  the  cyst  with  a  zone  of  breast 
tissue.  However,  in  the  smaller  group  when  we  find  no  such  cysts,  but 
a  circumscribed  or  diffuse  area  of  the  cystic  mastitis,  experience  teaches 
us  that  it  is  safer  to  remove  the  breast. 

A  most  thorough  gross  and  microscopic  study  of  almost  300  such 
cases  shows  not  much  difference  in  the  breast  about  the  simple  cyst,  in 
the  chronic  cystic  mastitis  without  large  cysts,  and  in  the  chronic 
cystic  mastitis  associated  with  definite  carcinoma. 

I  have  submitted  a  large  number  of  these  cases  to  a  group  of  experi- 
enced pathologists  and  found  a  great  divergence  of  opinion.  It  would, 
therefore,  be  a  mistake  to  present  this  disease  as  a  well-established 
entity  in  which  exact  diagnosis  is  possible. 

Cancer  in  Chronic  Cystic  Mastitis. — In  18  cases  of  cancer  cysts  the 
presence  of  chronic  cystic  mastitis  in  the  surrounding  breast  has  been 
conspicuous  by  its  absence.  So  we  have  no  evidence  that  the  cancer 
cyst  begins  in  this  disease. 

When  scirrhus  and  medullary  carcinoma  predominate  in  the  picture 
of  the  tumor,  one  pays  little  attention  to  the  surrounding  breast,  as  an 
indication  for  operation. 

In  those  cases  in  which  at  the  exploration  we  do  not  find  a  zone  oi 
scirrhous  or  medullary  carcinoma,  but  an  area  of  chronic  cystic  mastitis 
as  pictured  in  Fig.  339,  the  difficulties  of  differential  diagnosis  in  the 
majority  of  cases  are  sufficient  to  justify  the  complete  excision  of  the 
breast,  and  in  some  cases  the  complete  operation  for  cancer. 

In  50  cases  we  have  made  the  diagnosis  of  benign,  chronic  cystic 
mastitis.  As  far  as  I  know,  not  a  single  one  of  these  patients  has  subse- 
quently died  of  cancer.  In  13  of  these  cases  the  small  zone  which 
was  palpated  before  operation  did  not  show  the  fully  developed  chronic 
cystic  mastitis  as  illustrated  in  Fig.  330,  but  rather  the  character  of  the 
breast  tissue  pictured  in  Fig.  321.  Microscopically,  the  tissue  excised 
showed  evidence  of  the  adenomatous  stage  only  (see  Fig.  312).  I  am 
inclined  to  think  that  careful  scrutiny  at  the  exploratory  incision  with 
the  aid  of  a  frozen  section  will  distinguish  these  cases  and  allow  a 
conservative  operation. 

In  18  cases  the  breast  was  completely  removed,  in  6  both  breasts, 
and  in  13  the  complete  operation  for  cancer  was  done. 

It  is  true  that  in  some  of  these  cases  there  was  no  indication  for 
either  the  removal  of  the  breast  or  the  complete  operation  for  cancer, 
because  gross  and  microscopically  the  tissue  removed  resembled  that  in 


6o8  REGIONAL    SURGERY 

the  first  group.  But  in  the  majority  of  cases  the  gross  appearance  of 
the  palpable  and  explored  area  corresponded  pretty  closely  to  that 
shown  in  Fig.  339,  and  the  microscopic  to  that  in  Figs.  312  to  320. 

It  is  interesting  to  note,  however,  that  the  breast  in  these  50  cases 
diagnosed  benign  chronic  cystic  mastitis  differed  very  little,  except 
in  degree,  from  170  cases  diagnosed  simple  cyst  in  chronic  cystic 
mastitis.  It  is  very  difficult  to  explain  the  development  of  the  large 
cyst  in  the  larger  group. 

In  128  cases  single  simple  cysts  similar  to  that  illustrated  in  Fig.  311 
were  present.  In  54  of  these  cases  only  the  cyst  and  a  zone  of  the 
breast  was  excised.  In  one  of  these  cases  three  years  later  a  cancer 
formed  in  another  zone  of  the  breast.     The  patient  presented  herself 


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Fig.  340. — Chronic  cystic  mastitis  with  multiple  cysts. 

Pathol.  No.  15359. — Complete  operation  for  cancer  in  1913.     White,  female,  aged  45; 

pain  15  months;  tumor  one  year  (disappeared  once).     1916,  three  years,  well. 

immediately,  it  was  recognized  at  the  exploratory  incision,  and  the 
patient  is  well  five  years  since  the  complete  operation  for  cancer. 
The  microscopic  appearances  of  the  breast  about  these  cysts  is  shown  in 
Figs.  312  to  320. 

In  forty-eight  cases  for  various  reasons  the  breast  was  excised. 
In  twenty-six  cases  the  operator  suspicious  of  malignancy  performed 
the  complete  operation  for  cancer.  In  a  few  cases  because  of  a  re- 
tracted nipple  and  dimpled  skin.  In  a  few  others  on  account  of  the 
complicated  gross  pathology  (Fig.  340)  multiple  minute  cysts  and 
dilated  ducts.     In  a  few  cases  after  microscopic  study. 

In  42  cases,  clinically,  there  were  multiple  tumors,  and  at  operation 
multiple  cysts  were  found  (Fig.  340).     In  10  of  these  cases  the  breast 


LESIONS    OF    THE    FEMALE   BREAST 


609 


was  preserved,  in  19  cases  one,  and  in  13  both  breasts  were  removed. 
The  microscopic  study  of  these  breasts  with  multiple  cysts  differs 
from  the  breast  containing  a  single  cyst  only  in  the  number  of  simple 
cysts,  and  as  a  rule  the  chronic  cystic  mastitis  is  present  to  a  larger 
extent. 

During  the  same  period  of  2$  years  we  have  recorded  25  cases 
of  cancer  in  chronic  cystic  mastitis  or  senile  parenchymatous  hyper- 
trophy.    In  none  of  these  cases  was  there  found  a  fully  developed  area 


Fig.  341. — Early  adenocarcinoma  in  adenomatous  areas. 
Pathol.  No.  13204. — Operation  in  1912,  exploration  followed  by  the  complete  operation 
for  cancer.     White,  female,  aged  49;  intermittent  retraction  of  the  nipple  18  months;  pain 
and  tumor  four  months.     Two  years  later  excision  of  other  breast  for  similar  condition. 
1916,  four  years,  well. 


of  scirrhous  or  medullary  carcinoma.  In  this  group  there  is  only  one 
patient  dead  of  cancer,  and  in  this  case  we  find  after  serial  sections  an 
area  of  fully  developed  cancer  about  which  no  pathologists  would 
disagree.  The  other  cases  have  all  been  submitted  to  a  number  of 
consulting  pathologists,  and  not  in  a  single  case  is  there  uniform 
agreement. 

It  is  important  to  note,  however,  that  in  every  one  of  these  cases  the 
breast  was  completely  removed  as  shown  in  Fig.  339.  In  four  cases  the 
excision  of  the  breast  was  the  extent  of  the  operation,  in  live  cases  the 

39 


6io 


REGIONAL   SURGERY 


operation  consisted  first  of  the  removal  of  the  tumor  followed  after  an 
interval  by  the  complete  operation  for  cancer. 


Fig.  342. — Adenocarcinoma  in  adenomatous  areas. 
Pathol.  No.  1 1 799. — Operation  in  191 1,  excision  of  tumor;  a  few  weeks  later  complete 
operation  for  cancer.     1916,  five  years,  well. 

White,  female,  aged  26,  tumor  two  months.     The  tumor  in  the  gross  resembled  Fig.  337. 


t0r-M 


Fig.  343. — Cancer  (?)  in  chronic  cystic  mastitis.     Photograph  of  the  section  of  breast 

removed. 
Pathol.  No.  5221. — Operation  in  1904,  excision  of  breast  only.     1916,  12  years  well. 
White,  female,  aged  46;  enlargement  of  one  quadrant  of  the  breast  four  months.     For 
microscopic  appearance  see  Fig.  344. 


It  seems  to  me  that  the  key  to  the  situation  is  the  one  case  in  which 
there  was  a  death  from  cancer  in  spite  of  the  complete  operation.     In 


LESIONS    OF    THE    FEMALE   BREAST 


6ll 


all  breasts  which  show  the  type  of  chronic  cystic  mastitis  as  illustrated 
in  Fig.  339  the  complete  operation  for  cancer  is  the  safer  procedure. 

Microscopic  Study. — When  these  cases  were  studied  under  the 
microscope  histological  pictures  were  found  never  observed  in  the  170 
cases  of  chronic  cystic  mastitis  with  large  cysts,  and  50  cases  of  chronic 
cystic  mastitis  without  large  cysts.  Figs.  341  and  342  have  been  con- 
sidered adenocarcinoma  beginning  in  adenomatous  areas  and  should  be 
comparedwithFigs.  312,313,314,  331  and  333.  Figs.  343  and  344  have 
been  looked  upon  as  adenocarcinoma  in  adenocystic  areas  and  should 
be  compared  with  Figs.  317,  328  and  329. 


Fig.  344-- 


-  Adenocarcinoma  on  adenocystic  area.     Compare  with  Figs.  317,  3  28  and 
329.     For  gross  appearance  and  history  see  Fig.  343. 


Duct  Carcinoma  {Comedo  Adenocarcinoma). — At  the  exploratory 
incision  this  has  such  a  distinct  gross  appearance  that  one  should  never 
fail  to  recognize  it.  It  may  appear  as  a  circumscribed,  but  not  encap- 
sulated tumor  similar  to  Fig.  337,  or  as  a  diffuse  area  involving  a  quad- 
rant, hemisphere  or  the  entire  breast,  as  in  Fig.  345.  From  the  cut 
surface  of  the  tumor,  no  matter  what  its  size,  one  can  express  worm-like 
necrotic  tissue  after  which  there  is  left  a  little  space,  as  shown  in  Fig.  345. 
Microscopically  (Fig.  346),  it  is  as  characteristic  as  in  the  gross,  and 
easily  distinguished  from  the  benign  duct  adenoma  (Fig.  319).     I  saw 


6l2  REGIONAL   SURGERY 

and  described  this  tumor  first  in  1893,  and  up  to  the  present  time  I 
have  records  of  23  cases,  in  which  the  tumor,  in  the  gross  and  micro- 
scopic appearance  resembled  Figs.  345  and  346.  In  not  one  of  these 
cases  has  there  been  metastasis  to  the  glands  in  the  axilla,  nor  have  any 
of  the  patients  died  of  cancer.  The  tumor  is  often  associated  with  re- 
traction of  the  nipple,  ulceration,  and  even  the  development  of  a 
fungus. 

Duct  cancer  resembles  chronic  cystic  mastitis  in  that  there  may  be 
a  circumscribed  area,  or  a  diffuse  change  in  part  of,  or  in  the  entire 
breast.  Comedones  and  duct  adenomas  are  not  infrequently  observed 
in  small  areas  in  chronic  cystic  mastitis. 


Fig.  345- — Duct  cancer,  involving  the  entire  breast  (comedo  adenocarcinoma).     Section 

of  breast  through  nipple. 
Pathol.  No.  15427. — Operation  in  1914,  exploratory  followed  by  complete  for  cancer. 
White,  female,  aged  38;  tumor  2  years,  associated  with  slight  discharge  of  grumous  material 
from  nipple  and  pain.     19 16,  well. 

In  a  larger  number  of  cases  this  duct  carcinoma  has  been  present  in 
small  or  large  areas  of  a  fully  developed  scirrhous  or  medullary  car- 
cinoma. In  the  latter  group  the  glands  often  show  metastasis,  and 
the  probability  of  a  cure  is  identical  with  that  in  the  fully  developed 
scirrhous  or  medullary  carcinoma. 

Adenocarcinoma  in  Cystic  Adenoma. — Cystic  adenoma  (Fig.  327) 
differs  from  chronic  cystic  mastitis  (Fig.  339)  only  in  its  encapsulation. 
Our  12  cases  diagnosed  cancer  in  cystic  adenoma  were  not  encapsulated 
tumors,  but  circumscribed,  resembling  Fig,  337.  In  many  of  the  cases 
the  tumors  were  of  long  duration — 5  to  25  years,  with  a  history  of 


LESIONS    OF   THE    FEMALE   BREAST 


613 


recent  growth.  In  a  few  the  tumor  had  been  observed  less  than  a  year. 
The  ages  of  the  patients  varied  from  twenty-nine  to  seventy-seven. 
Three  cases  were  observed  during  lactation.  A  few  of  these  cases 
undoubtedly  were  cancers,  because  the  patients  died  of  cancer.  In 
these  cases  there  were  distinct  areas  of  scirrhousor  medullary  carcinoma. 


.!'^-^(S^ 


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iff 


*'?>  •.•V'  ". 


':^/ 


# 


Fig.  346. — Duct  cancer  (comedo  adenocarcinoma). 
Pathol.  No.   2815. — Operation  in  1899,  complete  for  cancer  on  both  breasts.     White, 
female,  aged  52;  tumor  of  one  breast  two  years;  recent  ulceration  with  fungus  formation, 
Small  tumor  in  other  breast.    The  patient  lived  14  years  and  died  of  causes  other  than  cancer. 

Microscopically,  they  show  the  same  histological  picture,  as  already 
noted  of  cancer  in  chronic  cystic  mastitis  (Figs.  341,  342  and  344). 

It  will  always  be  safer  when  you  meet  a  circumscribed  tumor  as 
pictured  in  Fig.  337  to  treat  it  as  malignant,  even  if  it  has  a  cystic 
appearance  as  shown  in  the  tumor  in  Fig.  327. 


6i4 


REGIONAL   SURGERY 


Fig.  34.7 — Colloid  cancer.     Circumscribed  tumor  involving  a  large  portion  of  the  breast 

beneath  the  nipple,  showing  infiltration  of  the  breast  beyond  the  tumor. 
Pathol.  No.  9733. — Complete  operation  for  cancer  in  1909.     White,  female,  aged  31, 

tumor  two  years. 


Fig.  348. — Colloid  cancer. 

Pathol.  No.  4874. — Complete  operation  for  cancer  in  1903.     White,  female,  aged  43, 

tumor  nine  months.     1916,  13  years,  well. 


LESIONS    OF    THE    FEMALE    BREAST  615 

Colloid  Adenocarcinoma. — When  explored,  the  gross  appearance  of 
this  tumor  (Fig.  347)  is  sufficiently  characteristic  to  allow  a  positive 
diagnosis  and  indicate  the  immediate  complete  operation  for  cancer.  I 
have  received  a  number  of  colloid  cancers  in  the  laboratory  for  diagnosis 
the  operator  having  unfortunately  removed  the  tumor  alone.  In  every 
instance  there  has  either  been  recurrence,  or  death  from  cancer  in  spite 
of  a  second  operation.  The  microscopic  appearance  is  entirely  different 
from  any  other  lesion  of  the  breast  (Fig.  348). 

In  the  past  few  days  I  have  found  in  a  young  colloid  cancer,  areas  of 
intracanalicular  myxoma  (Fig.  335)  suggesting  that  this  cancer  may  origi- 
nate in  this  common  benign  tumor.  But  our  evidence  at  the  present 
time  is  too  slight  to  reach  a  positive  conclusion. 


Fig.  349. — Scirrhous  carcinoma.  A  somewhat  circumscribed  area,  but  showing  distinct 
dots  and  lines  in  contrast  with  Fig.  337.  Note  also  the  slight  retraction  of  the  nipple.  The 
surrounding  breast  is  chiefly  fat.  There  is  a  little  stroma  between  the  tumor  and  the 
nipple.     There  is  no  gross  evidence  of  chronic  cystic  mastitis. 

Pathol.  No.  18840. — Recent  case.     For  microscopic  appearance  see  Fig.  308. 

Malignant  Papillomatous  Cyst. — In  my  experience  with  25  cases 
the  malignant  papillomatous  cyst  has  shown  clinical  evidence  of  its 
malignancy  by  changes  in  the  skin  or  nipple  in  over  85  per  cent, 
of  the  cases.  The  probabilities  are,  therefore,  when  you  explore  a 
papillomatous  cyst,  that  the  tumor  is  still  benign.  The  malignant 
papilloma  has  lost  its  papillomatous  form  and  looks  entirely  different 
from  the  papilloma  in  Fig.  321.  It  has  assumed  a  fungous  appearance. 
In  addition,  the  cyst  wall  at  the  base,  and  the  breast  beyond  are 
infiltrated. 

When  one  explores  a  breast  tumor  and  finds  a  cyst  partially,  or 
completely,  filled  with  a  distinct  papilloma,  and  at  the  base  of  the 
papilloma  there  is  a  distinct  cyst  wall  separating  the  papilloma  from 
the  breast,  and  the  breast  beyond  looks  normal,  excision  of  the  cyst 


6l6  REGIONAL   SURGERY 

with  a  zone  of  breast  is  a  justifiable  operation.  In  all  other  cases  it 
is  safer  to  perform  the  complete  operation  for  cancer. 

Scirrhous  Carcinoina. — Until  recently  (Fig.  33  7)  I  felt  that  one  should 
always  recognize  a  scirrhous  carcinoma  at  an  exploratory  incision 
by  its  hardness,  by  its  gritty  sensation  to  the  knife,  by  its  peculiar 
markings  in  fine  dots  and  lines  (Fig.  349). 

In  my  past  experience  I  had  observed  scirrhous  cancer  as  a  dis- 
tinctly circumscribed  area  and  as  an  infiltrating  zone  from  the  size 
of  the  end  of  the  Httle  finger  up  to  a  tumor  involving  the  entire  breast. 
In  every  instance  the  gross  appearance  was  the  same  and  the  diagnosis 
confirmed  by  the  microscopic  section. 

But  now  that  women  are  seeking  advice  earlier  we  are  seeing 
apparently  for  the  first  time  a  new  group  of  tumors  (see  Fig.  337). 
Frozen  sections  will  probably  not  help  us  in  the  differential  diagnosis 
(see  Fig.  338). 

The  circumscribed  and  infiltrating  areas  which  resemble  scirrhous 
carcinoma  should  at  the  present  time  be  treated  as  malignant.  I  am 
confident  that  if  we  attempt  to  dift'erentiate  and  be  conservative  in 
the  smaller  group  too  many  mistakes  will  be  made  in  performing  in- 
complete operations  for  cancer.  Apparently  the  circumscribed  area 
is  a  precancerous  lesion,  and  it  will  probably  be  safer  never  to  be  con- 
servative in  removing  the  lesion  only,  at  least  until  we  have  had  a 
much  larger  experience. 

Cancer  in  Old  Mastitis. — On  page  607  I  have  referred  to  the 
possibility  of  a  carcinoma  developing  in  the  residual  scar  after  mastitis. 
In  all  of  our  cases  the  patients  have  been  aware  of  the  area  of  induration 
after  mastitis  from  periods  of  15  to  30  years.  They  have  come  under 
observation  only  after  observing  recent  growth,  with  further  changes 
in  the  skin  and  nipple.  Recently  I  have  had  the  opportunity  to 
excise  a  chronic  mastitis  scar  in  the  benign  state.  The  cancer  in  all 
of  these  cases  has  always  been  of  the  scirrhous  type,  but  in  every 
instance  we  have  been  able  to  recognize  with  the  microscope  (Fig.  308) 
the  remains  of  the  old  ducts  surrounded  by  a  zone  of  chronic 
inflammatory  tissue. 

Medullary  Carcinonia. — This  tumor,  when  small  and  clinically 
benign,  is  practically  always  a  somewhat  circumscribed  area.  I  can 
imagine,  but  I  have  never  seen,  an  encapsulated  medullary  carcinoma. 
It  would  probably  then  suggest  an  intracanalicular  myxoma,  and  the 
frozen  section  would  differentiate  it.  The  medullary  carcinoma,  in 
contrast  with  scirrhus,  is  friable,  little  pieces  can  easily  be  picked  out 


LESIONS    OF    THE    FEMALE   BREAST 


617 


Fig.  350. — Hemorrhagic  medullary  carcinoma.     Photograph  of  section  through    the 

breast,  showing  circumscribed,  cellular,  hemorrhagic  tumor. 

The  breast  is  rather  fatty  and  fibrous,  with  no  evidence  of  chronic  cystic  mastitis. 


Fig.  351. — A  tumorof  the  breast  clinically  malignant.     The  nipple  is  retracted,  the  skin 
dimpled.     The  Cfenter  of  the  breast  is  occupied  by  an  indurated  mass. 
Pathol.  No.  2392. — Complete  operation  for  cancer  in  1S98.     No  metastasis  to  .  axilla. 
1916,  18  years  well.     White,  female,  aged  51;  tumor  two  years  and  five  months.     Discharge 
from  nipple  18  months. 

The  removed  breast  was  the  seat  of  an  infiltrating  scirrhus.     No  evidence  of  the  paren- 
chyma of  the  breast  remaining. 


6l8  REGIONAL   SURGERY 

with  the  knife.  Now  and  then  these  tumors  are  very  hemorrhagic 
(Fig.  350). 

Sarcoma. — jMetastatic  sarcoma  is  so  infrequent  in  the  breast  that 
it  need  not  be  considered  here.  I  have  seen  one  case  among  almost 
1800  breast  lesions.  A  correct  diagnosis  would  not  help,  nor  an  in- 
correct one  harm  the  patient.  In  this  case  the  tumors  were  multiple, 
felt  distinctly  benign  and  appeared  a  few  months  after  an  operation 
for  a  malignant  tumor  of  the  ovary. 

The  most  common  sarcoma  of  the  breast  is  a  secondary  develop- 
ment in  an  intracanalicular  myxoma.  The  tumor  as  a  rule  is  large, 
usually  occupying  more  than  half  of  the  breast.  The  best  rule  is 
to  treat  all  large  intracanalicular  myxomas  on  the  diagnosis  of  sarcoma. 
The  differential  diagnosis  from  the  large  aberrant  fibroadenoma  can 
be  made  at  the  exploratory  incision.  The  gross  appearance  of  a 
fibroadenoma  (see  Fig.  336)  should  easily  be  differentiated  from  the 
intracanalicular  myxoma. 

The  fibroadenoma  as  a  rule  is  in  younger  women,  and  the  larger 
aberrant  tumor  is  always  outside  the  breast.  Apparently,  however, 
differential  diagnosis  between  these  two  forms  has  been  difl&cult. 
I  have  mentioned  this  before  (page  604). 

The  indigenous  sarcoma  of  various  types  and  mixed  tumors  con- 
taining cartilage  and  myxomatous  tissue  offer  no  dijB&culty  at  all 
at  the  exploratory  incision;  although  circumscribed,  their  appearance 
will  never  be  confused  with  that  of  any  benign  breast  tumor. 

Clinically  Malignant  Tumors  (Fig.  351). — If  we  define  retraction  of 
the  nipple,  dimpling  and  other  changes  of  the  skin  already  described, 
and  ulceration  of  the  nipple  as  the  usual  signs  of  cancer,  we  have 
therefore  the  description  of  a  clinically  malignant  tumor  of  the  breast. 
All  of  these  signs  have  been  carefully  described  (page  576).  We 
must  also  remember  that  these  symptoms  may  now  and  then  be  as- 
sociated with  benign  breast  lesions.  However,  except  in  the  few 
instances  already  defined,  it  seems  safer  to  perform  the  complete 
operation  for  cancer  without  an  exploratory  incision. 

Operation. — No  woman  should  be  subjected  to  an  operation  for  a 
breast  lesion,  except  for  a  lactation  mastitis  abscess,  unless  the  surgeon 
is  prepared  to  make  the  diagnosis  at  the  exploratory  incision  and  to 
perform  the  complete  operation  for  cancer  if  indicated. 

Now  that  women  are  seeking  advice  earlier  I  am  inclined  to  think 
that  a  most  painstaking  clinical  history  and  examination  along  the  lines 


LESIONS  OF  THE  FEMALE  BREAST  619 

laid  down  in  the  beginning  of  this  article  will  be  most  helpful,  and  more 
so  than  in  the  past. 

By  this  we  must  exclude  a  group  (getting  larger  each  day)  in  which 
operation  is  not  indicated. 

When  the  palpable  breast  lump  is  clinically  benign  the  operation 
begins  with  an  exploratory  incision. 

Exploratory  Incision. — There  is  no  objection  to  performing  this 
under  novocaine,  with  or  without  gas.  The  incision  should  be  made 
from  the  areola  out  and  over  the  tumor,  pushing  the  breast  and  tumor 
toward  the  knife.  Divide  the  skin  and  subcutaneous  fat.  Clamp 
the  bleeding  points.  These  clamps  will  do  for  retractors.  Inspect 
the  exposed  breast  tissue.  Have  a  dry  held.  Often  the  blue  dome  of 
the  simple  benign  cyst  is  exposed,  and  not  infrequently  in  malignant 
tumors  one  can  see  and  feel  the  infiltrated  breast  tissue  at  this  point 
of  the  incision. 

When  the  exposed  breast  looks  and  feels  normal,  cut  through  it, 
still  pushing  the  tumor  toward  the  knife;  clamp  the  bleeding  points; 
inspect  the  breast  tissure  carefully  as  it  is  divided.  It  is  surprising 
how  rapidly  the  benign  cyst  or  encapsulated  benign  tumor  is  exposed 
to  view,  while  in  the  malignant  tumor  one  often  feels  that  they  are  not 
being  exposed  as  rapidly  as  expected. 

This  is  explained  by  the  fact  that,  in  the  benign  cystic  and  solid 
tumors,  the  zone  of  breast  is  practically  normal,  and  one  palpates  the 
tumor  more  easily  through  the  breast  tissue,  while  in  the  malignant 
tumor  a  very  small  area  may  feel  so  much  larger  than  it  really  is,  that 
when  you  cut  into  the  palpable  mass,  you  do  not  expose  the  real  disease, 
because  it  is  in  the  center  of  it. 

In  my  own  experience  I  have  never  missed  a  benign  tumor  at  the 
exploratory  incision,  no  matter  how  small.  But  on  a  few  occasions 
I  have  had  the  greatest  difficulty  in  isolating  the  very  small  scirrhous 
cancer,  and  a  number  of  cases  have  come  to  me  in  which  the  carcinoma 
had  been  missed  at  the  exploratory  incision.  Ditliculty,  therefore,  in 
readily  exposing  the  palpable  tumor  at  the  exploratory  incision  is  sug- 
gestive of  malignancy. 

The  moment  you  find  signs  of  malignancy,  disinfect  the  wound  with 
pure  carbolic  acid  followed  by  alcohol,  and  then  use  the  cautery  if  you 
desire.  I  have  tried  the  cautery  for  exploration  of  breast  tumors  and 
have  so  far  found  it  unsatisfactory.  Again,  one  can  disinfect  more 
rapidly  with  carbolic  and  alcohol  than  with  the  cautery. 


620  REGIONAL   SURGERY 

Having  disinfected  the  supposed  malignant  tumor,  close  the  skin 
wound  and  proceed  with  the  complete  operation  for  cancer. 

Some  surgeons  cut  out  a  piece  for  frozen  section,  others  cut  out  the 
entire  tumor  for  inspection  and  frozen  section.  This  has  not  been  the 
practice  nor  the  teaching  of  Dr.  Halsted  and  I  have  no  regrets,  because 
I  have  always  followed  his  precept  and  all  my  accumulated  evidence  is 
in  favor  of  it. 

It  is  surprising  how  rapidly  one  can  differentiate  at  this  exploratory 
incision.  The  benign  cyst  and  the  encapsulated  tumor  are  recognized 
at  once,  and  for  these  tumors  a  local  operation  is  usually  justifiable. 
In  the  other  groups  it  is  safer  to  perform  the  complete  operation  for 
cancer  anyway.  Of  course,  there  are  some  exceptions.  To  recognize 
these  exceptions  requires  great  experience.  If  the  majority  follow 
the  rule  as  stated,  there  should  be  no  incomplete  operations  for  cancer. 
There  will  be  some  complete  operations  for  benign  lesions.  Up  until 
the  last  few  years  in  my  observation  this  was  done  in  about  lo  per  cent, 
of  the  benign  lesions.  In  the  last  three  years  this  has  increased  in 
experienced  hands  to  15  per  cent. 

An  incomplete  operation  for  cancer  of  the  breast  offers  the  patient 
little  more  probability  of  a  cure  than  if  there  had  been  no  operation 
at  all.  Operations  in  two  stages  do  not  compare  in  the  results  with 
one-stage  operations. 

Removal  of  Tumor. — Having  exposed  the  benign  cyst  or  the  encap- 
sulated benign  tumor,  remove  it  with  a  zone  of  breast  through  the 
incision  made  for  exploration.  Nothing  is  gained  by  enucleation.  If 
one  attempts  to  enucleate  one  may  leave  behind  pieces  of  tumor  tissue 
which  may  become  foci  of  second  growth.  I  have  observed  such  recur- 
rences after  enucleation  chiefly  in  mixed  tumors  of  the  parotid,  but 
recently  a  number  have  come  under  my  observation  in  which  the  tumor 
had  been  enucleated  from  the  breast. 

It  is  simpler  to  remove  these  tumors  by  cutting  through  the  breast. 
It  also  gives  one  the  opportunity  to  see  the  breast  tissue. 

Closure  of  the  Woimd. — The  breast  tissue  should  be  approximated 
with  interrupted,  rapidly  absorbing  catgut,  as  a  rule  in  three  layers. 
The  subcutaneous  fat  and  the  skin  are  approximated  with  fine  silk. 
Buried  silk  and  chromic  catgut  in  breast  tissue  may  give  rise  to  a  chronic 
mastitis  resulting  in  a  palpable  tumor  which  may  be  very  difficult  to 
distinguish  from  a  malignant  one. 

The  breast  wound  should  be  closed  most  carefully,  as  hematoma 
usually  results  in  a  breakdown. 


LESIONS    OF   THE    FEMALE   BREAST  62 1 

The  dressing  on  the  breast  should  be  snug,  fixed  with  adhesive  straps 
and  reinforced  with  a  bandage. 

When  such  details  have  been  followed,  the  wounds  heal,  the  patient 
and  the  surgeon  are  not  worried  by  scar-tissue  tumors  or  scar  pain,  and 
the  subsequent  function  of  the  breast  is  never  impaired.  I  have 
removed  at  one  sitting  three  tumors  from  one  breast  and  have  operated 
twice  on  the  same  breast  for  a  benign  tumor  without  sacrificing  the 
breast,  or  leaving  any  mutilation. 

I  have  observed  a  few  examples  where  after  the  removal  of  a  benign 
breast  tumor  a  huge  defect  could  be  seen  and  felt  in  the  breast.  The 
deformity  is  really  more  unsightly  than  the  removal  of  the  breast,  and, 
of  course,  it  is  avoidable. 

In  my  experience  it  is  perfectly  justifiable  to  confine  the  operation  to 
the  removal  of  the  tumor  only  in  simple  cysts,  papillomatous  cysts, 
galactocele,  cystic  adenoma,  fibroadenoma  and  small  intracanalicular 
myxoma — that  is  the  typical  benign  cyst  and  encapsulated  benign 
tumors.  It  is  justifiable  to  remove  one  or  more  of  such  tumors  leaving 
the  breast.  I  would  be  more  inclined  to  remove  the  entire  breast  in 
multiple  cystic  adenomas  than  in  any  other  form  of  multiple  benign 
lesion. 

In  young  girls  one  may  palpate  what  seems  to  be  a  distinct  tumor 
as  a  rule  in  the  axillary  quadrant.  Yet,  when  one  cuts  down  upon 
such  an  area  there  is  no  cyst,  no  encapsulated  tumor,  simply  a  zone  of 
breast  tissue  to  be  distinguished  from  the  surrounding  white  breast 
tissue  by  numerous  pink,  elevated  dots.  The  youth  of  the  patient 
helps  in  the  differentiation.  Microscopically,  we  find  adenomatous 
hypertrophy  (Fig.  312).  Especially  in  young  girls  this  peculiar  lesion 
should  be  recognized,  because  excision  of  this  zone  is  sufficient.  The 
probabilities  are  that  operation  is  not  indicated  at  all,  but  when  one 
feels  a  distinct  tumor,  we  know  it  is  safer  to  operate.  But  we  must 
also  recollect  that  we  may  not  find  a  distinct  tumor,  but  just  an  area 
of  such  hypertrophied  breast. 

The  same  condition  may  be  present  in  older  women  at  the  cancer 
age;  we  feel  an  area  of  induration  or  even  a  distinct  tumor,  which  as  a 
rule  is  painful  and  tender.  However,  when  we  cut  down  upon  this 
zone  we  are  disappointed — there  is  neither  a  cyst,  nor  an  encapsulated 
tumor,  nor  really  any  distinct  disease.  My  records  show  a  number  of 
such  cases  in  which  the  surgeon  has  been  able  to  recognize  the  be- 
nignity of  this  lesion  and  has  had  the  courage  of  his  conviction.  None 
of  these  patients  lost  the  breast,  nor  have  any  of  them  suffered  from 


622  REGIONAL    SURGERY 

this  wise  conservatism.  Unfortunately,  however,  in  a  larger  group 
the  operators  have  either  been  unable  to  make  the  diagnosis,  or  have 
lacked  conviction.  The  operation  has  either  been  complete  removal  of 
the  breast  or  that  for  cancer.     Not  one  of  these  patients  has  died  of  cancer. 

To  the  less  experienced  perhaps  a  frozen  section  would  be  very- 
helpful  in  differentiating  this  non-encapsulated  zone  of  adenomatous 
hypertrophy.  Next  to  intracanalicular  myxoma  it  is  the  easiest  to 
recognize  from  its  microscopic  appearance  (Fig.  312). 

If  one  can  recognize  the  chronic  lactation  mastitis  with  abscess, 
excision  of  the  zone,  if  the  lesion  is  single,  is  sufficient.  My  figures 
show  that  in  at  least  30  per  cent,  of  the  cases  the  chronic  lactation 
mastitis  has  been  treated  on  a  diagnosis  of  malignancy. 

It  appears  to  be  the  uniform  rule  in  tuberculosis  of  the  breast 
to  remove  the  entire  breast,  but  in  the  beginning  the  tuberculosis 
may  be  a  single  focus,  and  I  am  confident  that  the  time  is  coming 
when  these  younger  women  will  not  be  unnecessarily  mutilated  for  a 
small  focus  of  tuberculosis  in  one  breast. 

Excision  of  Breast. — In  some  cases  we  can  proceed  with  excision 
of  the  breast  without  an  exploratory  incision  on  account  of  the  ability 
to  make  a  pretty  definite  diagnosis  of  a  benign  lesion  involving  the 
entire  breast. 

In  diffuse  virginal  and  gravidity  hypertrophy  in  which  the  en- 
largement has  reached  a  certain  stage  one  can  proceed  at  once  with  the 
removal  of  one  or  both  breasts.  In  mastitis  with  multiple  sinuses  and 
abscesses  this  operation  is  possible  without  an  exploratory  incision. 
In  multiple  tumors  in  women  over  30  years  of  age  when  the  breast 
is  riddled  with  shot-like  areas,  the  majority  of  surgeons  excise  the 
breast.  This  is  also  true  when  the  sinus,  induration  and  the  history 
suggest  tuberculosis. 

In  my  experience  the  deliberate  excision  of  one  breast  on  the 
positive  clinical  diagnosis  of  a  benign  lesion  is,  with  rare  exceptions,  a 
procedure  fraught  with  danger;  of  mutilation  for  a  benign  lesion  on 
one  hand,  or  of  an  incomplete  operation  for  cancer  on  the  other.  For 
all  single  palpable  areas,  and  even  for  cases  in  which  the  breast  shows 
multiple  areas,  it  is  on  the  whole  safer  to  explore.  The  excision  of  the 
breast  rests  upon  the  character  of  the  local  lesion,  the  pathology  of 
the  surrounding  breast,  the  age  of  the  patient,  and,  to  some  extent, 
the  wishes  of  the  patient. 

I  have  already  described  the  local  lesion  in  which  it  seems  safe  to 
confine  our  operation  to  the  excision  of  the  tumor  only. 


LESIONS    OF   THE    FEMALE   BREAST  623 

A  number  of  patients,  especially  those  who  have  nursed  children, 
prefer  to  have  the  breast  removed  rather  than  run  the  risk  of  second 
operations.  In  all  benign  single  lesions  there  is  always  the  possibility 
of  multiple  foci  which  later  grow. 

Older  women  with  huge,  fatty  breasts  are  probably  protected  by 
the  complete  removal  of  the  breast,  because  in  breasts  of  this  kind 
it  is  difficult  to  exclude  other  lesions,  and  when  cancer  begins  it  spreads 
rapidly. 

When  the  chronic  cystic  mastitis  exposed  in  removing  the  single 
tumor  is  very  extensive  in  the  breast,  patients  will  probably  be  saved 
second  operations  by  the  primary  removal  of  the  breast.  This  is 
such  an  easy  condition  to  recognize  that  mistakes  are  rarely  made,  but 
many  breasts  are  unnecessarily  removed  for  this  condition  in  its  earlier 
stages. 

In  chronic  cystic  mastitis  without  large  cysts,  except  in  the  early 
adenomatous  stage,  it  is  my  opinion  that  it  is  safer  to  remove  the 
entire  breast.  If  one  can  recognize  the  chronic  lactation  mastitis 
and  the  multiple  galactoceles,  excision  of  the  breast  is  sufficient,  but 
in  my  experience  the  majority  of  surgeons  have  performed  the  com- 
plete operation  for  cancer  when  this  disease  was  exposed  at  the 
exploration. 

In  every  instance  the  breast  after  removal  should  be  cut  up  in 
serial  sections  with  a  large  amputating  knife  and  studied  for  a  possible 
area  of  cancer.  Frozen  sections  can  be  made  and  in  some  instances 
may  be  helpful.  In  the  presence  of  cancer  the  complete  operation 
should  follow  at  once. 

When  for  any  reason  I  have  decided  to  excise  the  breast  I  always, 
by  a  most  painstaking  dissection,  attempt  to  protect  the  individual 
by  the  complete  removal  of  all  breast  tissue,  because  theoretically,  any 
bit  of  breast  tissue  left  behind  might  act  as  a  focus  for  a  subsequent 
benign  or  malignant  tumor. 

The  complete  excision  of  the  breast  is,  on  the  whole,  rather  more 
difl&cult  that  the  complete  operation  for  cancer,  because  more  skin  is 
saved,  and  the  dissection  of  this  skin  from  the  breast,  to  be  properly 
done,  is  a  delicate  procedure,  and  very  bloody,  unless  numerous  bleeding 
points  are  clamped. 

The  nipple  and  areola  are  always  removed.  The  area  of  skin 
beyond  this  varies  with  the  size  of  the  breast :  the  larger  the  breast  the 
larger  the  area  of  skin;  the  larger  the  mass  removed,  the  smaller  the 
area  of  skin  necessary  to  cover  the  defect. 


624  REGIONAL   SURGERY 

The  incision  should  begin  over  the  rib  near  the  rectus  muscle  in 
about  the  parasternal  line  and  curve  upward  and  outward  to  a  point 
where  the  breast  and  pectoralis  major  muscle  meet  in  the  axilla;  a 
second  curved  incision  below  encircles  the  nipple,  the  areola,  an  area  of 
skin  outlined  for  removal.  These  skin  flaps  should  be  dissected  prac- 
tically clean  of  subcutaneous  fat  over  the  breast  tissue.  It  is  simpler  to 
dissect  the  upper  flap  first  until  the  pectoralis  major,  and  sometimes  the 
rectus  muscle,  is  exposed.  It  facilitates  the  dissection  to  remove  the 
pectoral  fascia  with  the  breast.  The  dissection  proceeds  until  the  axil- 
lary fat  is  exposed.  Now  the  skin  fat  on  the  outer  side  is  dissected  until 
the  latissimus  dorsi  and  serratus  magnus  muscles  are  exposed.  This 
mass  is  then  lifted  up,  and  the  connection  with  the  chest  wall  divided 
from  the  lower  point  up  toward  the  axilla.  In  this  way  the  fat  and 
fascia  of  the  space  below  the  axilla  on  the  chest  wall  are  removed  with 
the  breast,  and  the  dissection  is  thus  clean  and  complete  as  for  cancer 
up  to  the  base  of  the  axilla. 

Up  to  this  point  the  dissection  is  just  as  complete  as  in  the  operation 
for  cancer,  except  that  the  area  of  skin  is  a  little  smaller  and  the  pectoralis 
major  muscle  is  not  removed. 

In  the  opinion  of  the  majority  the  removal  of  the  pectoral  muscle 
is  made  to  allow  a  better  exposure  of  the  axilla,  and,  therefore,  a  more 
thorough  dissection. 

If  the  operation  for  the  removal  of  the  breast  proceeds  along  this 
line  up  to  this  point,  we  really  have  nothing  more  to  do,  if  early  cancer 
is  demonstrated,  than  to  remove  the  pectoral  muscle  and  complete  the 
axillary  dissection. 

It  is  my  rule,  in  the  majority  of  cases  to  clamp  the  axillary  attach- 
ments with  the  broad  ligament  clamp  and  make  serial  sections  of  the 
breast,  searching  for  cancer.  In  two  instances  cancer  was  demonstrated, 
and  the  operation  for  cancer  immediately  followed.  In  one  of  these 
cases  it  is  more  than  six  years  since  this  was  done,  and  there  has  been 
no  recurrence;  the  other  case  is  recent. 

If  the  operator  decides  that  the  breast  condition  is  benign,  the 
vascular  attachments  to  the  axillary  area  are  ligated  and  the  wound  is 
closed. 

It  is  my  habit  to  close  the  wound  with  interrupted  fine  black  silk. 
The  wound  after  the  excision  of  the  breast  usually  fills  with  serum.  I 
am  inclined  to  think  that  this  is  due  to  torn  lymph  vessels,  because  this 
accumulation  is  very  much  less  frequent  after  the  complete  operation 
for  cancer  when  the  skin  wound  is  primarily  closed. 


LESIONS    OF   THE   FEMALE   BREAST  625 

When  the  technique  has  been  good,  I  have  been  unable  to"  tell 
whether  it  is  better  to  drain  these  wounds  or  not.  If  you  do  not  drain, 
the  serum  can  be  expressed  after  the  fourth  or  fifth  day.  No  drainage 
will  absolutely  prevent  accumulation,  and  some  of  the  serum  will  have 
to  be  expressed  in  any  event.  These  wounds  require  the  most  careful 
after-dressing  to  prevent  infection,  and  with  each  dressing  the  bandage 
must  be  snug. 

There  is  another — and  very  important — reason  for  the  complete 
removal  of  the  breast  along  these  Unes.  My  figures  show  that  some 
cases  diagnosed  adenocarcinoma  have  remained  well  and  free  from 
recurrence  of  the  diseases  from  5  to  i6  years  after  the  operation.  The 
number  of  cases  of  this  early  type  of  disease  will  increase  when 
women  seek  advice  early  after  the  first  appearance  of  the  tumor.  At 
the  present  time  we  are  not  in  a  position  to  do  such  a  restricted  opera- 
tion, if  it  is  our  opinion  that  the  lesion  is  cancer.  However,  if  one  has 
decided  to  remove  the  breast,  let  it  be  done  in  this  more  radical  way 
for  the  benefit  of  the  patient.  There  is  no  more  mutilation,  or  danger, 
nor  is  the  period  of  convalescence  longer  or  more  uncomfortable ;  nor 
are  the  chances  of  a  painful  scar  any  greater. 

Excision  of  Both  Breasts. — I  had  hoped  that  our  long  and  intensive 
study  of  the  pathology  of  breast  lesions  in  relation  to  the  results  after 
the  different  operations  would  throw  some  light  on  cases  in  which  the 
pathology  of  one  breast  would  indicate  the  removal  of  the  other.  But 
at  the  present  time  I  do  not  feel  justified  in  giving  any  rule.  It  seems 
safer  to  apply  to  the  other  breast  the  rules  already  stated. 

The  palpable  lesion,  single  or  multiple,  in  each  breast  is  subjected 
to  the  same  diagnostic  scrutiny. 

If  a  patient  has  a  tumor  in  one  breast,  no  definite  tumor  in  the 
other,  but  multiple  shot-like  nodules  or  areas  of  induration,  it  is  prob- 
ably safer  to  remove  both  breasts,  if  the  first  breast  removed  is  the  seat 
of  chronic  diffuse  mastitis  without  large  cysts,  or  of  multiple  cystic 
adenoma. 

When  both  breasts  are  removed  at  one  or  two  operations,  the 
technique  as  described  should  be  employed  for  each  breast. 

Operation  for  Sarcoma. — When  there  is  a  tumor  involving  almost 
half  or  more  of  the  breast  and  the  skin  over  it  is  not  involved,  the 
chances  are  that  it  is  not  carcinoma,  but  that  it  is  either  a  benign  intra- 
canalicular  myxoma  or  some  form  of  sarcoma.  In  these  cases  the  breast 
will  have  to  be  sacrificed,  and  as  most  of  these  tumors  are  sarcoma,  it 
is  better  to  treat  all  as  sarcoma. 
40 


626  REGIONAL    SURGERY 

The  technique  of  the  operation  is  very  similar  to  that  already  described 
for  the  excision  of  the  breast.  The  area  of  skin  should  be  larger  and 
should  include  all  of  the  skin  covering  the  palpable  tumor.  In  addition, 
the  pectoral  muscle  beneath  the  breast  and  tumor  should  be  removed. 
Theoretically,  there  is  no  objection  to  performing  the  complete  operation 
for  cancer,  but  it  seems  unnecessary.  In  our  early  cases  of  sarcoma  in 
intracanalicular  myxoma  in  which  the  tumor  and  breast  only  were 
removed,  recurrence  in  the  pectoral  muscle  took  place  in  every  instance. 
Since  we  have  removed  the  muscle  there  have  been  no  recurrences. 
In  a  few  of  these  cases  we  have  also  removed  the  axillary  glands.  These 
did  not  show  metastasis. 

T  the  present  time  we  have  never  saved  a  sarcoma  of  the  breast 
other  than  sarcoma  in  intracanalicular  myxoma.  The  patients  died 
of  metastasis  to  the  lungs. 

Complete  Operation  for  Cancer. — In  this  operation  there  is  re- 
moved an  area  of  skin,  a  wider  area  of  subcutaneous  fat,  the  major 
pectoral  muscle,  except  its  clavicular  bundle;  the  minor  pectoral  muscle 
is  either  removed  or  divided,  and  there  is  a  complete  dissection  of  the 
axillary  tissue  without  injury  to  the  main  vessels  and  nerves. 

The  most  striking  part  of  Halsted's  first  report  was  not  the  per 
cent,  of  ultimate  cures,  because  the  time  of  observation  was  too  short, 
but  the  low  per  cent,  of  local  recurrences  in  the  scar,  and  even  of  re- 
gionary  recurrences  on  the  chest  wall.  The  description  of  the  technique 
of  the  operation  in  Halsted's  first  and  subsequent  reports  may  not  have 
been  entirely  clear,  but  the  operation  as  first  performed  by  him  was 
ideal,  and  all  of  his  students  who  have  followed  his  teaching  will  agree 
that  his  method  was  the  first  truly  complete  operation  for  cancer 
of  the  breast. 

From  a  most  painstaking  study  of  the  local  growth  of  cancer  in 
the  breast  and  from  the  position  of  local  and  regionary  recurrences 
I  am  convinced  that  the  chest-wall  dissection  is  the  most  essential 
feature  of  the  operation.  Now  that  patients  are  seeking  advice 
earlier,  the  complete  axillary  dissection  is  becoming  relatively  less 
important. 

Even  in  small  malignant  tumors  of  the  breast  there  may  be  wide- 
spread dissemination  of  cancer  cells  through  the  channel  of  the  gland 
ducts.  I  am  inclined  to  think  that  this  occurs  before  extensive  lym- 
phatic dissemination  in  the  breast.  For  this  reason,  as  described 
under  excision  of  the  breast,  every  particle  of  breast  tissue  must  be 
removed. 


LESIONS    OF    THE    FEMALE    ERKAST  627 

Connective-tissue  rich  in  lymphatics  radiates  between  the  skin 
and  the  breast  beneath,  and  when  cancer  reaches  the  skin,  it  may 
disseminate  rapidly  within  a  considerable  zone  of  skin.  For  the 
reason  in  all  cancers  of  the.  breast  with  the  slightest  involvement 
of  the  skin  the  skin  area  removed  should  be  larger,  and  with  the  ex- 
tent of  involvement  of  the  skin  the  larger  and  larger  should  be  the  area 
of  skin  excised. 

One  should  never  see  breast  tissue  during  the  operation,  only  fat, 
fascia  and  muscle. 

In  planning  the  area  of  skin  to  be  removed  the  tumor,  not  the  nipple, 
should  be  its  center.  In  this  zone  of  skin  the  nipple  and  areola  should 
always  be  included.  In  thin  patients  with  little  subcutaneous  fat 
always  take  a  larger  zone  of  skin,  because  in  such  instances  it  is  more 
difficult  to  dissect  the  skin  from  the  breast  than  when  there  is  more 
fat.  It  is  far  better  for  the  inexperienced  to  begin  with  the  excision  of 
a  huge  area  of  skin  and  restrict  this  as  experience  is  gained,  rather  than 
the  reverse. 

Freedom  from  recurrence  in  the  region  of  the  scar  does  not  de- 
pend upon  the  closure  or  the  healing  of  the  wound,  but  upon  the 
extent  of  the  surgeon's  dissection  in  relation  to  the  local  extent  of  the 
disease. 

I  have  had  a  large  opportunity  to  compare  the  results  of  different 
methods  of  operation  and  different  surgeons,  and  I  am  confident 
that  the  large  number  of  the  local  recurrences  is  not  due  to  the  ex- 
tensive local  growth  of  the  cancer  at  the  time  of  the  operation,  but 
to  the  restricted  zone  of  skin  and  subcutaneous  tissue  removed  by  the 
surgeon. 

Skin-grafting  can  be  done  a  week  later  with  little  or  no  anaesthesia 
at  all. 

In  planning  the  operation  always  make  it  a  little  more  extensive 
than  the  local  conditions  seem  to  indicate.  The  surgeon  must  watch 
himself  all  the  time  not  to  "cut  corners,"  to  remember  that  the  object 
of  this  operation  is  to  make  the  best  attempt  possible  to  get  rid  of  the 
malignant  disease. 

It  does  not  make  much  difference  where  one  begins  or  where  one 
ends  in  this  operation  or  in  what  sequence  the  various  steps  follow 
each  other,  providing  each  step  is  well  executed.  In  the  majority  of 
cases  it  seems  simpler  to  dissect  the  upper  skin  flaps  first,  exposing  the 
pectoralis  major  muscle.  Except  when  the  tumor  is  situated  in  the 
axillary  zone,  it  is  unnecessary  to  prolong  the  incision  down  the  arm. 


628  REGIONAL   SURGERY 

After  exposing  this  muscle  I  prefer  to  make  all  of  the  skin  dissection, 
except  in  the  base  of  the  axilla,  until  muscle  is  exposed.  It  facilitates 
most  of  the  operation  to  prolong  the  incision  down  over  the  rectus. 
This  helps  in  enlarging  the  exposure  of  the  subcutaneous  fat  and  later 
allows  one  to  bring  the  skin  flaps  closer  together. 

Muscle. — The  pectoralis  major  muscle  is  so  divided  that  the 
clavicular  bundle  is  left  undisturbed.  As  the  division  extends  upward 
toward  the  rib,  push  down  the  lymphatic  tissue  and  vessels  which 
lie  between  the  two  muscles.  Then  continue  the  division  of  the 
muscle  along  the  sternum,  clamping  the  intercostals.  Extend  the 
division  down  along  the  sternum  to  the  rectus  and  clean  the  rectus  and 
serratus  magnus  of  all  fat  and  fascia  to  be  removed  with  the  tumor 
mass. 

Now  inspect  the  axilla.  If  no  glands  can  be  felt,  you  know  it 
is  a  favorable  case.  If  glands  are  felt  above  the  acromio-thoracic 
vessels  and  in  the  apex  of  the  axilla,  one  must  resect  a  V-shaped  piece 
of  the  clavicular  bundle  of  the  pectoral  up  to  the  clavicle  and  make 
en  bloc  dissection  of  this  muscle,  the  vessels,  and  all  the  tissue  in  the 
space  between  the  clavicle  and  vessels  in  this  area.  In  favorable 
cases  this  is  unnecessary,  and  the  acromio-thoracic  vessels  can  be  left 
undisturbed  just  as  we  leave  the  supraclavicular  fossa  out  of  the  zone 
of  dissection. 

In  proceeding  with  the  axillary  dissection  I  prefer,  after  inspection, 
to  isolate  the  vessels  and  fat  which  pass  from  the  apex  of  the  axilla 
down  over  the  minor  into  the  major,  clamp  them  and  burn  through 
with  the  cautery.  This  exposes  the  minor.  The  minor  may  be 
divided  in  favorable  cases,  and  each  half  used  as  a  retractor.  In 
unfavorable  cases  it  should  be  completely  removed.  In  unfavorable 
cases  the  dissection  of  the  acromio-thoracic  area  begins  before  the 
removal  of  the  minor,  as  this  gives  more  room  for  attacking  the  muscle. 
But  in  favorable  cases  when  you  divide  the  minor  this  is  done  first, 
and  the  dissection  is  begun  at  the  apex  of  the  axilla,  first  isolating  the 
subclavian  muscle  over  the  vein. 

I  have  always  followed  the  example  of  Halsted  and  isolated  the 
vessels  separately,  ligating  with  fine  silk. 

One  cleans  everything  from  the  vein  from  the  apex  to  the  arm; 
then  there  is  exposed  the  cavity  between  the  subscapular  muscle 
and  the  chest  wall.  In  making  this  dissection  one  must  use  a  com- 
bination of  blunt  sweeping  with  a  piece  of  gauze  as  well  as  the  knife. 
The  process  of  cleaning  everything,  leaving  only  bare  muscle,  major 


LESIONS    OF   THE    FEMALE   BREAST  629 

vessels  and  nerves,  passes  down  over  the  teres  major  and  latissimus 
dorsi  until  it  strikes  the  subcutaneous  fat  at  the  base  of  the  axilla. 
Having  reached  this  point  one  can  push  the  mass  over  into  the  wound 
and  proceed  with  the  dissection  of  the  skin-flap  over  that  area  not 
included  in  the  first  and  second  step. 

Closure  of  the  Wound. — It  is  better  to  skin-graft  than  to  use  ten- 
sion and  have  sloughing  skin-flaps.  I  agree  with  Halsted  that  swelling 
and  oedema  of  the  arm  are  dependent  chiefly  upon  wound  infection, 
ever  so  slight.  For  this  reason  cover  the  vessels  and  make  a  good  axil- 
lary fornix,  then  close  the  remainder  of  the  wound,  if  you  can,  without 
tension;  if  not,  skin-graft  then  or  later,  according  to  experience. 

In  a  few  cases  where  there  is  no  axillary  flap  on  account  of  the  dis- 
section necessary  to  remove  a  malignant  tumor  in  the  axillary  quadrant, 
one  can  easily  make  a  flap  from  the  posterior  skin  area. 

The  direction  of  the  skin  incision  in  length  is  that  described  for  the 
removal  of  the  breast.  The  area  of  skin  removed  within  this  line  varies 
according  to  the  position  of  the  tumor,  the  position  of  the  breast,  the 
size  of  the  breast,  and  the  thickness  of  the  subcutaneous  fat.  It  is 
impossible,  and  therefore  would  be  futile  to  make  one  tj-pe  of  incision 
fit  all  cases. 

Neck. — When  the  highest  axillary  glands  are  involved  and  one  has 
made  the  V-shaped  division  of  the  clavicular  bundle  of  the  major,  and 
the  microscope  shows  these  glands  to  be  involved,  the  complete  dis- 
section  of  the  supraclavicular  glands  should  be  done  at  a  second 
operation. 

It  is  quite  true  that  the  chances  of  a  permanent  cure  in  such  cases 
are  not  more  than  about  6  per  cent.  However,  when  this  operation  is 
properly  done  there  is  rarely  local  recurrence,  and  many  patients  whose 
lives  are  not  saved  are  made  more  comfortable,  if  this  dissection  is  done 
at  the  proper  time. 

Supraclavicular  Dissection. — From  about  the  middle  of  the  sterno- 
mastoid  muscle  make  an  incision  down  to  the  junction  of  the  inner  and 
middle  thirds  of  the  clavicle  to  join  another  incision  which  runs  along 
the  clavicle.  Reflect  the  two  flaps  outlined  by  the  above  cuts.  Expose 
and  clean  the  sterno-mastoid  down  to  the  clavicle.  Isolate  and  ligate 
the  external  jugular  vein.  Beginning  high  up,  dissect  all  fatty  tissue 
from  the  internal  jugular  vein  downward  to  within  i  or  2  cm. 
of  the  apex  of  the  triangular  exposed  area.  From  without  inward 
clear  the  clavicle  and  subclavian  vessels;  by  pulling  on  the  mobilized 
mass  of  tissue  the  important  dissection  between  the  internal  jugular 


630  "  REGIONAL   SURGERY 

and  the  subclavian  veins  is  completed.  Lift  the  mobilized  triangular 
mass  so  as  to  isolate  and  clamp  its  vascular  attachments  to  the 
posterior  muscles  of  the  neck.  On  the  left  side  lookout  for  the 
thoracic  duct.  At  the  base  of  the  triangle  the  large  number  of  ves- 
sels emerging  from  between  the  posterior  muscles  cause  much  bleeding 
unless  they  are  isolated  and  separately  clamped. 

Excision  of  Vein. — Now  and  then  in  the  axillary  dissection  the  cancer 
is  adherent  to  the  axillary  vein.  There  is  no  objection  whatever  to 
isolate  and  ligate  a  segment  of  this  vein  if  necessary. 

Hemorrhage. — When  the  tumor  is  on  the  sternal  periphery  of  the 
breast  and  for  this  reason  you  are  forced  to  a  dissection  close  to  ribs, 
intercostal  muscles  and  sternum,  you  will  experience  diJS&culty  in 
clamping  and  ligating  the  perforating  intercostal  vessels. 

Should  a  clamp  miss  the  vessel,  do  not  attempt  to  re-clamp  by  push- 
ing the  instrument  into  the  intercostal  muscle,  you  may  perforate  the 
pleura.  The  hemorrhage  can  be  checked  by  holding  a  bit  of  gauze 
there. 

Recently  in  cases  of  this  kind  I  have  hastened  and  simplified  matters 
by  using  the  electric  cautery  knife.  We  now  know  this  is  a  safer  pro- 
cedure when  near  cancer,  and  if  one  uses  it  slowly  the  vessels  divided 
rarely  require  clamping. 

Shock. — After  a  considerable  comparative  experience  with  nitrous- 
oxide  gas  anaesthesia  and  ether-drop,  I  prefer  ether  in  the  majority  of 
cases  of  complete  operation  for  cancer.  Here  there  is  no  necessity  for 
deep  narcosis.  Shock  is  rarely  observed,  and  if  one  checks  hemorrhage, 
it  should  never  be  fatal. 

Mortality. — When  the  complete  operation  for  cancer  was  extended 
to  the  complete  supraclavicular  dissection  and  skin-grafting  at  one  sit- 
ting, the  mortality  increased  from  about  3^^  per  cent,  to  3.  Now  that 
this  neck  operation  has  been  given  up  as  a  routine  procedure  and  when 
done  is  always  performed  at  a  second  operation,  the  mortality  has 
fallen  to  less  than  3^  per  cent. 

Late  Results. — In  a  short  article  of  this  kind  there  is  no  space  to 
consider  this  phase  of  the  subject.  All  our  patients  should  be  carefully 
watched,  because  even  after  complete  operation  for  cancer  there  is  the 
remaining  breast  to  be  looked  after.  Every  one  of  these  patients  should 
be  given  the  proper  information  for  her  own  protection:  "If  you  feel  a 
lump  return  at  once  for  inspection.  No  matter  how  well  you  feel, 
return  for  an  examination  at  certain  given  intervals." 

Function  of  the  Arm. — In  the  first  place  good  function  is  dependent 
upon  healing  without  infection;  second,  upon  early  and  continuous  use. 


INDEX 


Abbe.     Gasserian  ganglion,  176 
Aberrant  fibro-adenoma,  breast,  598 

tumors,  breast,  560 
Abscess,  acute,  neck,  324 

alveolar,  157,  186 

brain,  60,  61,  318,  584 

breast,  564,  584 

chronic  lactation,  594 
tuberculosis,  595 

Dubois  thymus,  534 

intracranial,  317 

ligneous  neck,  340 

orbit,  142 

peritonsillar,  240 

septum,  nose,  260 

subpericranial,  10 

tongue,  200 
Abnormal  involution,  breast,  606 
Acromegaly,  larynx,  443 
Actinomycosis,  face,  137,  155 

mouth,  190 

neck,  339 

nose,  265 

salivarj'  glands,  233 
Adamantoma  jaw,  163 
Adamkiewicz,  cerebral  compression,  42 
Addison's  disease,  thymus,  536 
Adenitis,  cervical  tuberculosis,  333 

face,  135 
Adenoids,  pharyngeal,  270 
Adenoma,  cystic,  breast,  597 

mouth,  191 

thyroid,  486,  508 
Adeno-carcinoma,  breast,  584,  611 

nose,  269 

salivary  glands,  234 
Adhesive  mediastinal  pericarditis,  553 
Adhesions  in  nasal  cavity,  260 
Adiamorrhysis,  42 
After  treatment,  cleft  palate,  105 

excision,  jaw,  181 

larj-ngectomy,  435 


After  treatment,  laryngostomy,  445 

thyrotomy,  432 

tracheotomy,  451 
Age  incidence,  tumors,  breast,  558 
Air  embolism,  veins,  neck,  355 
Albrecht.     Development,  lip,  80,  82,  87 
Alcoholic  coma,  44 
Alcohol  injections,  angioma,  face,  139 

neuralgia,  167,  173 
Aleukemic  lymphoma,  344 
AUantois,  development,  74 
Alopecia  sj'philitica,  1 1 
Alveolar  abscess,  157,  186 
Alveolus  jaw,  excision,  177 
Amputation,  epiglottis,  427 
Anaemia,  brain,  43,  369,  377 

cerebral,  43,  369,  377 

Hodgkin's  disease,  347 
Anastomoses,  facial  nerve,  169 
Anastomosis,  thoracic  duct,  357 
Anatomy,  lymphatics  neck,  325 

mastoid,  309 

nasal  sinuses,  275 

parathyroid,  512 

scalp,  I 

thymus,  531 

thyroid,  475 
Anderson,  J.  H.     Gastroscopy,  462 
Aneurism,  carotid,  375 

cirsoid,  15 

neck,  373 

orbit,  146 

scalp,  19 

subclavian,  371,  379,  386 

tongue,  212 

traumatic,  369,  370 
Anesthesia,  direct  laryngoscopy,  402,  407 

excision,  jaw,  179 

in  external  laryngeal  operations,  430 

insufflation,  430,  547 

in  nasal  operations,  253 

oesophagosoopy,  452 

operations  in  exophthalmic  goiter,  492 

tonsillectomy,  243 
631 


632 


INDEX 


Anesthesia,  tracheotomy,  446 
Angina,  Ludwig's,  186,  322 
Angioma  cavernosum,  15 

face,  139,  I  S3 

mouth,  19 1 

nose,  267 

oesophagus,  472 

racemose,  15 

simplex,  scalp,  14 

tongue,  211 
Angular  gyrus,  54 
Ankylosis,  jaw,  125 
Ankylotic  stenosis,  larynx,  442 
Annandale.    Loose  tempero-maxillary 

cartilage,    125 
Anosmia,  276 
Anthrax,  face,  134 
Antrum,  Highmore,  281 

mastoid,  306,  309 
Antyllus,  aneurism,  378 
Apoplexy,  traumatic  late,  54 
Aran's  law,  fracture  skull,  25 
Artery,  carotid,  aneurism,  375 
injuries,  368 

common  carotid,  clamping,  219 

external  carotid,  ligation,  179,  219 

innominate,  374 

middle  meningeal,  45,  49,  67 

subclavian,  371,  379,  386 

vertebral,  371 
Arteries,  thyroid  ligation,  491 

neck  wounds,  353 
Arteriovenous  aneurism,  neck,  380 

tongue,  212 
Arteriosclerosis,  373 
Arteritis,  372,  373 
Arthritis,  tempore- maxillary,  125 
Arthroplasty,  jaw,  126 
Aspiration,  pericardial,  555 
Atheroma  (vessels),  373 

scalp,  12 
Atrophy,  thyroid,  487 

neck  muscles,  386 
Atresia  nasi,  260 

Auditory  canal,  external  diseases,  292 
Auditory  nerve,  injuries,  35 
Auer.     Anesthesia,  430 
Auricles,  accessory,  no 
Avulsion,  trifacial  nerve,  174 
Axilla,  cancer  breast,  576 
Axillary  glands,  cancer  breast,  628 

vein,  cancer  breast,  630 


B 


Baby,  blue,  440,  442 
Ballance.     Facial  paralysis,  170 
Bardeen.     Development,  72 
Basedow's  disease,  475,  488. 
Berkeley.     Hjqjoparathyroidism,  511 
Bezold's  mastoiditis,  307 
Beebe's  serum,  491 
Benign  tumors,  breast,  581 
Bergmann.     Injury  vagus,  358 

Meningocele  spuria,  7 
Bevan.     Actinomycosis,  340 
Bier's  hyperemia,  breast,  565 
Billings.     Hodgkin's  disease,  352 
Billroth.     Chronic  cystic  mastitis,  606 

Cleft  palate,  104 

Neuroma  scalp,  14 
Binnie.     Depressed  scars  face,  132 
Birth  palsy,  364 
Black  tongue,  210 
Bladder,  urinary  development,  74 
Bland-Sutton.     Deformities,  112,  114 

Development,  ear,  84 
Blandin  and  Nuhn's  glands,  cysts,  226 
Bleeding  in  fractured  skull,  31,  32 
Bleeding  nipple,  571 

venous  sinuses,  skull,  49 
Blood  examination,  thymus,  539 

Hodgkin's  disease,  347 
Bloodgood.     Epithelioma  lip,  148,  149 
Bios.     Tubercular  adenitis,  333 
Blue  baby,  440,  442 
Bodies,  foreign,  in  ear,  295 
larynx,  410 
oesophagus,  457 

Hassall's,  534 
Boils,  face,  133 

scalp,  II 
Bollinger.     Apoplexy,  54 
Bolton.     Injuries  brachial  plexus,  366 
Bone,  replantation,  skull,  36 
Bougies,  oesophagus,  466 
Boxer's  ear,  294 
Boyce.     CEsophagoscopy,  452 
Brachial  plexus,  injury,  361 
Brain,  abscess,  60,  61,  318 

cephalalgia,  62 

concussion,  39 

compression,  41 

dementia,  post-traumatica,  64 

encephalitis,  61 


INDEX 


633 


Brain,  epilepsy,  62 

fissure.     Rolando  and  Sylvian,  67 

gunshot  injuries,  37 

headaches,  traumatic,  62 

hernia,  58 

infections,  59 

insanity,  62 

laceration,  51 

leptomeningitis,  58 

meningitis,  58  et  seq. 

neurasthenia,  62 

pachymeningitis,  59 

paralysis,  general  insanity,  64 

Potts'  puffy  tumor,  60,  61 

pressure,  40 

psychasthenia,  62 

sinus  thrombosis,  60 

symptoms,  meningitis,  59 

topography,  65 

traumata,  23 

treatment,  wounds,  58 

trephining,  hemostasis,  65 

wounds  of,  57 
Branchial  arches  and  clefts,  76 

cysts  and  fistula,  112 
Brauer.  Cardiolysis,  554 
Braun.  Neurectomy,  174 
Breast,  557 

aberrant  tumors,  560 

abnormal  involution,  606 

abscess,  564,  584,  594,  595 

adenocarcinoma,  comedo,  611,  615 

adenoma,  cystic,  597,  612 

age  incidence,  tumors,  558 

benign  tumors,  581 

caked,  564 

cancer  cysts,  596 

carcinoma,  584  et  seq. 
duct,  611 

children,  559,  569 

colloid  adenocarcinoma,  615 

complete  operation,  cancer,  626 

cysts,  557,  580,  584,  586,  603 

disappearing  tumors,  579,  580 

diseases  of,  557 

duration,  tumors,  561 

duct,  carcinoma,  611 

etiology,  562 

examination  of  tumors,  623 

exploratory  operation,  breast,  582,  619 

fibroadenoma,  597 

function  arm,  operation,  breast,  630 


Breast,  galactocele,  557,  567,  584,  591 

hypertrophy,  559,  563,  621 

indications  operation,  breast,  618 

induration,  564 

infection,  563 

intracanalicular  myxoma,  597,  599 

lactation,  557,  564,  594 

mastitis,  557,  564,  580,  591,  594,  603, 
616,  623 

medullary  carcinoma,  616 

menopause,  569 

mortality  operation,  breast,  630 

multiple  tumors,  580 

nipple,  bleeding,  571 
care  of,  565 
retracted,  572,  618 
ulcer,  573 

operation  for  cancer,  626 

operation,  exploratory,  58?,  618 
for  benign  tumors,  620,  622 
for  sarcoma,  625 

Paget's  disease,  573 

pregnancy,  563 

Reclus'  disease,  606 

results  operation,  breast,  630 

Schimmelbusch's  disease,  606 

schirrhus,  584  et  seq.,  616 

symptoms,  diseases,  570 

time  for  removal  tumors,  561 

trauma,  562 

tuberculosis,  565,  584,  595 

tumors,  557,  581,  584  et  seq. 
benign,  581 
border-line,  583 
Brewer.    Laryngectomy,  433 
Bristow.     Injuries  brachial  plexus,  366 
Bronchi,  foreign  bodies,  411 

deformities,  439 

stenosis,  439 
Bronchoscopy.     See  Laryngoscopy,  401 
Brophy's  operation,  cleft  palate,  97 
Br>'ant,  J.  D.     Operation,  angioma,  7 
Buccal  cavity,  disinfection  of,  218 

actinomycosis,  190 

burns,  196 

injuries,  195 

leucoplakia,  190 

Ludwig's  angina,  186 

noma,  185 

operations  for  cancer,  193 

stomatitis,  183 

s>'philis,  188 


634 


INDEX 


Buccal  cavity,  tuberculosis,  189 

tumors,  191 

wounds,  19s 
Bullet  wounds,  heart,  545,  550 
neck,  353 

skull  and  brain,  37 
Burrell.     Innominate  aneurism,  374 
Bunting.     Hodgkin's  disease,  351 
Burns,  face,  132 

mouth,  196 

oesophagus,  462 

tongue,  198 
Butlin.     Lar3rngotomy,  180 

Lymphatics  neck,  331 

Tumors  thyreo-glossal  duct,  116 


Caked  breast,  564,  567 
Calculi,  salivary,  231 
Cannula.     Butlin's,  180 

laryngostomy,  445 

Levy-Baudouin,  173 

Ch.  Jackson's,  440,  441,  447 
Cancer,  breast,  584 

chronic  cystic  mastitis,  607 

cysts,  breast,  596 

larynx,  426 

muscles,  neck,  389 

tongue,  214 
Caput  succedaneum,  5 
Carcinoma,  duct,  breast,  611 

face,  139,  140 

jaw,  162 

mamma,  584 

mouth,  192 

nose,  269 

pharynx,  246 

salivary  glands,  234 

thymus,  534 

thyroid,  509 
Carbuncles,  face,  134 

neck,  321 

scalp,  II 
Carbon  dioxide  snow,  13 
Cardiolysis,  553 
Cardiospasm,  464 
Carotid  aneurism,  375 

artery,  injuries,  368 

exterior  ligation,  179,  219 

gland,  397 
Carter,  repair  nose,  252 


Cartilage,   intra-articular,   temporo   maxil- 
lary, 125 
Cavernous  angioma,  neck,  396 

lymphangioma,  397 
Celluloid  plate  in  skull,  37 
Cephalalgia,  traumatic,  62 
Cephalhematoma,  5,  6 
Cephalo-hydrocele,  traumatic,  7 
Cerebral  abscess,  60,  61,  318,  584 

anaemia,  369,  377 

compression,  41 

complications,  middle  ear  diseases,  317 

concussion,  39 

hernia,  58 

irritation,  54 

laceration,  51 
Cerebellar  abscess,  319 
Cerebral  topography,  65 
Cervical  adenitis,  tubercular,  333 

glands,  cancer  breast,  639 

lymphatics,  325 

plexus,  nerves,  359 

rib,  365 
Chancre,  tongue,  206 
Cheek,  carcinoma  of,  193 

clefts  of,  108 
Chest  injuries,  545 
Cheyne-Stokes  respiration,  43 
Chiene.     Cerebral  topography,  65 
Chipault.     Intracranial  hemorrhage,  50 
Chondroma,  nose,  267 
Chondrotomy,  thymus,  542 
Chronic  cystic  mastitis,  585,  591,  603,  612 

623 
Chvostek's  test,  524 
Chjdo thorax,  356 
Clairmont.     Angioma  scalp,  18 
Clamping  base,  heart,  551 
Clamps,  Crile's,  219 
Cleft  palate,  87 
Clefts,  nose,  108 

Circulatory  disturbance,  thymus,  543 
Cirsoid  aneurism,  15 
Colloid  adenocarcinoma,  breast,  615 
Coma,  alcoholic,  44 
Coma,  differential  diagnosis,  44 
Comedo  adenocarcinoma,  breast,  611 
Commotion,  cerebral,  39 
Complications,  fractured  skull,  45 

middle  ear  diseases,  317 
Compression  of  brain,  41,  45 

oesophagus,  464 


INDEX 


63: 


Compression  of  trachea,  440 
Concussion,  brain,  39 
Condyle,  lower  jaw,  fracture,  121 
Congenital  anomalies,  oesophagus,  463 
Contusions,  neck,  352 

scalp,  3 
Corona  veneris,  1 1 
Corrosives,  oesophagus,  462 
Coryncbacterium  Hodgkini,  352 
Cranial  nerves,  injuries,  33 
Cranio-cerebral  topography,  65 
Crile.     Anesthesia  thyroid  operations,  492 
Crile.     Laryngectomy,  433 
Crile's  clamps,  219 
Curette,  adenoid,  272 
Cushing.     Cephal-hematoma,  5 

Neuroma,  scalp,  12 

Operation,  Gasserian  ganglion,  176 
Cutaneous  horns,  13,  155 
Cyrtometer,  65 

Cystadenoma,  breast,  597,  612 
Cystoma,  jaws,  164 
Cysts  of  Blandin  and  Nuhn's  glands,  226 

branchial,  112 

breast,  557,   579,   580,   584,   586,   596 
615,  623 

dental,  164 

hydatid,  muscles,  neck,  388 

larynx,  423 

median,  neck,  225 

mucous,  mouth,  195 

neck,  392 

of  orbit,  144 

salivary  glands,  238 

scalp,  7,  12 

thymus,  534 

thyroid,  487 

tongue,  225 

urachus,  75 

D 

Da  Costa,  oesophagoscopy,  457 

Dalrymple's  sign,  490 

Dangers,  excision,  tongue,  218 
exophthalmic  goiter,  498 

Dawbarn.     Cancer,  tongue,  225 

Deanesley.     Thoracic  duct,  357 

Death,  thymic,  529,  536 

Deformities,  congenital,  nose  and  face  other 
than  hare-lip,  107 
auricles,  accessory,  no 
branchial  cvsts  and  fistulas,  112 


Deformities,  cheek,  clefts  of,  108 
cysts,  branchial,  112 

median,  neck,  115,  225 
eyelid,  clefts  of,  108 
fissures,  nose,  107 
fistulae,  branch,  112 
median,  neck,  115 
lines  of  fusion,  80,  107 
lip,  lower,  in 
macrostoma,  no 
mandibular  tubercles,  1 10 
median  cysts  and  fistulae,  neck,  115, 
225 
hare-lip,  107 
microstoma,  no 
mouth,  no 
sinuses,  lip,  108 
face,  scars,  132 
larynx,  trachea,  bronchi,  439 
nose,  249 
oesophagus,  463 
Deguise.     Salivarj^  fistulae,  229 
Delavan.    Laryngectomy,  429 
Delorme's  operation,  553 
Dementia,  post-traumatic,  64 
Demmer.     Tuberculous  adenitis,  336 
De  Quervain.     Ligation,    inferior    thyroid 

artery,  493 
Dermoids,  face,  155 
neck,  115,  392 
nose  and  face,  108,  109,  in 
scalp,  12 
Deschamp's  needle,  105 
Development,  69 
Deviated  septum  nasi,  254 
Diagnosis,  actinomycosis,  340 
adenoids,  271 
ankylosis,  jaw,  126 
benign  tumors,  breast,  581 
compression,  brain,  44 
fracture,  skull,  30 
Hodgkin's  disease,  347 
lesions,  tongue,  217 
middle  meningeal  hemorrhage,  48 
otitis  media,  305 
phlegmone  ligneuse,  340 
sinusitis,  277 
thymic  disease,  539 
tubercular  adenitis,  neck,  336 
tumors,  carotid  gland,  399 

larynx,  426 
wounds,  heart,  546 


636 


INDEX 


Differential  pressure,  anesthesia,  547 
Diffuse  lipoma,  391 
Diphtheria,  larynx,  420 

nose,  261 
Diplopia,  exophthalmic  goiter,  490 
Direct  laryngoscopy,  401 
Disease,  Addison's,  thymus,  536 

Basedow's,  475,  488 

Graves',  475,  488 

Hodgkin's,  344 

Paget's  nipple,  573 

Reclus',  606 

Rigg's,  158 

Schimmelbusch,  606 

Tornwaldt's,  273 

wool-sorter's,  134 
Diseases  of  breast,  557 

muscles,  neck,  386 

parathyroids,  522 

scalp,  II 

vessels,  neck,  372 
Disinfection  of  mouth,  218 
Dislocation,  jaw,  129 
Diverticula,  pharyngectomy,  113 
Diverticulum,  bladder,  75 

oesophagus,  467 
Douche,  nasal,  278 
Dowd.     Cysts,  neck,  392 

Tuberculous  adenitis,  336,  338 
Drainage,  antrum,  281 

wounds,  heart  and  pericardium,  552 
Dubois  abscess,  534 
Duchenne-Erb  paralysis,  363 
Duct,  carcinoma,  breast,  611 

Stenson's,  injuries,  228 

thoracic,  wounds,  356 

thyreo-glossal,  78 

Wharton's,  calculi,  231 
Duration,  tumors,  breast,  561 
Duret.     Concussion,  brain,  40 
Dyball.     Aneurism,  orbit,  146 
Dyspeptic,  tongue,  209 
Dyspnoea,  thymus,  542 

E 

Ear,  external, 

foreign  bodies,  295 
frost-bite,  294 
furunculosis,  292 
ot-haematoma,  294 
skin  diseases,  297 
syringe,  296 


Ear,  external,  tumors,  297 

Ear,  middle,  298 

•        acute  mastoiditis,  306 

chronic  mastoiditis,  308 

earache,  299 

incisions  tympanum,  300 

intracranial  complications,  317 

necrosis  bone,  304 
ossicles,  304 

operations  on  mastoid,  309 

otitis  media,  299 

perforations,  305 

polypi,  304 
Ear,  development,  83 

external  deformities,  112 
Eczema,  ear,  297 
Effusions,  pericardial,  554 
Electrolysis,  angioma  face,  139 
Elephantiasis  nervorum,  13 
Elsberg.     Anesthesia,  430 

Clamping  base  heart,  551 
Embolic  endarteritis,  372 
Embolism,  air,  neck,  355 
Embryology,  parathyroid,  512 

thymus,  529 
Emissary  veins  scalp,  3 
Emphysema,  fractured  skull,  33 

mediastinal,  420 
Encephalitis,  61 
Encephalocele  orbit,  146 
Endarteritis,  372 
Endoaneurismorrhaphy,  378 
Endothelioma  mouth,  192 

neck,  390 

scalp,  20 

tongue,  214 
Enucleation  goiters,  508 
Epiglottis,  malignant  ulcer,  427 
Epilepsy  traumatic,  62 
Epithelioma  face,  146 

larynx,  426 

lip,  147 

mouth,  192 

oesophagus,  472 

scalp,  12,  13,  21 

tongue,  214 
Epulis,  160 

Erb  Duchenne  Paralysis,  363 
Erb's  phenomena,  tetany,  524 
Erichsen,  injury  phrenic  nerve,  361 
Erysipelas  scalp,  10 
Ethmoidal  sinuses,  276,  281 


INDEX 


637 


Etiology  hare-lip  and  cleft  palate,  88 

tumors,  breast,  562 
Excision  adenoids,  272 

breast,  622 

cancer,  mouth  or  cheek,  193 

glands,  neck,  338 

hypertrophied  turbinates,  256 

jaws,  179  et  seq. 

parotid,  236 

sublingual  gland,  235 

submaxillary  gland,  235 

tongue,  217 

tumors,  breast,  620 
jaw,  177,  193 
Exophthalmic  goiter,  475,  485,  488 

thj'mus,  536 
Exophthalmos,  499 

pulsating,  57 
Exploration,  tumors,  breast,  582,  619 
Exposure,  heart,  549 
Extra-dural  abscess,  317 

-cephal  hematoma,  5 
Eye  symptoms,  goiter,  490 
Eyelid,  clefts  of,  108 
Eyelids,  development,  85 

tumors,  139 

wounds,  138 
Eyes,  defects  of,  109 
Evans.     Parathyroids,  513,  517 


Face,  actinomycosis,  137,  155 
adenitis,  135 
anthrax,  134 
burns,  132 

congenital  deformities,  107 
depressed  scars,  132 
development,  80 
epithelioma,  146 
eyelids,  wounds,  138 
glands,  lymph,  135 
infections,  133 
injuries  and  diseases,  117 
lymph  glands,  135 
nose,  fractures,  122 

treatment,  123 
rodent  ulcer,  151 
temporo-maxillary  joint, 

arthritis,  125 
tuberculosis,  face,  137 
tumors,  139,  146 


Face,  wounds,  130,  138 
Facial  nerve,  314 

nerve,  anastomosis,  169 
injury,  35 

paralysis,  168 
Fat  transplantation,  sears,  face,  132 
Faucial     Ij'mphoid    tissues,    hypertrophy, 

241 
Ferguson.     Parathyroids,  514 
Fibro-adenoma,  breast,  597 
Fibro-lipoma,  tongue,  211 
Fibroma,  jaws,  163 

molluscum,  13 

mouth,  191 

nasopharynx,  273 

nose,  267 
Fibromyoma,  tongue,  211 
Fibromyxoma,  nasopharynx,  274 
Fissure,  fractured  skull,  29 

Rolando,  67 

Sylvian,  67 
Fissures,  nose,  107 
Fistula,  lower  lip,  in 

tracheal,  445 

tracheo-oesophageal,  463 
Fistulas,  branch,  112 

salivary,  228 
Fluoroscope,  oesophagus,  460 
Forceps,  adenoid,  272 
Foreign  bodies  in  ear,  295 

larynx,  410 

oesophagus,  456 

in  tongue,  198 
Fountain.     Fracture,  jaw,  121 
Fraenkel-Hodgkins  disease,  351 
Fracture,  deformity  nose,  repair,  252 
Fractures,  larj'nx,  418 

lower  jaw,  117 

nose,  122 

skull,  23,  28 
base,  31 
vault,  30 

upper  jaw,  123 
Frazier.     Facial  paralysis,  1 70 
Fredet.     Thoracic  duct,  356 
Fronhofer.     Hare-lip,  90 
Frontal  sinus,  276,  284,  285 
Frost-bite,  ear,  294 
Furuncles,  ear,  292 

face,  133 

scalp,  II 
Furunculosis,  nose,  260 


638 


INDEX 


H 


Gags,  mouth,  98 

Galactocele,  557,  567,  5S4,  591,  623 

Galvano-puncture  angioma,  153 

Gangrenous  stomatitis,  185 

Gangrene  tongue,  201 

Gasserian    ganglion,    neuralgia,    165,    168, 

176 
Gastroscop)^,  451,  461 
General  paralysis,  insane,  64 
Gland,  carotid,  397 

parotid  excision,  236 
Glands,  epithelioma,  lip,  149 

sublingual,  excision,  235 

submaxillary,  excision,  235 

Hodgkins  disease,  344 

lymphatic,  breast,  627 
face,  135 
neck,  325 
tongue,  220 

parathyroid,  511 

salivary,  227 
Glanders,  nose,  265 
Glioma,  orbit,  146 
Globus  hystericus,  464 
Glossitis,  199 

sclerosing,  207 
Glossodynia  exfoliativa,  210 
Glossopharyngeal  nerve,  injury,  357 
Gliick.     Laryngectomy,  436 
Goat's  milk,  goiter,  490 
Goiter.     See  Thyroid,  475  et  seq. 

non-toxic,  500 

toxic,  non-exophthalmic,  500 
Graefe's  sign,  exophthalmic  goiter,  489 
Granulomata  larynx,  423 
Grant,  D.     Thyrotomy,  428 
Grant,    W.    W.      Operation,    cancer    lip, 

150 
Graves  disease,  475,  488 
Green.     Air  embolism,  355 

suture,  phrenic  nerve,  361 
Grier.     Fluoroscopic  screen,  416 

gastroscopy,  462 
Guibe.     Development  ear,  83 
Gumma  lip,  148 

muscles  neck,  388 
Gummata  scalp,  11 

tongue,  207 
Gunshot  injuries,  skull  and  brain,  37 

wounds,  heart,  545,  550 


Heemangioma,  cavernous,  396 

hypertrophic,  153 

neck,  396 
Halsted.     Exploratory    operation,    breast, 
620 

Operation,  cancer  breast,  626 

Parathyroids,  513,  517,  519 

Treatment  aneurism,  374 
Hamilton.     Fracture,  jaw,  118 
Hammar.     Thymus,  529 
Hare  lip,  87 

etiology,  88 

median,  107 

treatment,  90  et  seq. 
Hart.     Status  thymicus,  534 

Tracheotomy,  542 
Hassalt's  bodies,  534 
Haymann.     Hare  lip,  90 
Heart,  545 

adhesive  mediastinal  pericardium,  553 

anesthesia  methods,  549 

cardiolysis,  553 

compression  base,  551 

diagnosis  wounds,  546 

injuries,  545 

operations  on,  549 

osteoplastic  exposure,  549 

rupture,  540 

suture,  550 

symptoms,  wounds,  546 

treatment,  wounds,  547 

wounds,  545 
Heath's  mastoid  operation,  316 
Helferich.     Ankylosis  jaw,  127 
Hematoma,  meningeal,  46 
Hematomata,  scalp,  2,  4,  30 
Hemopericardium,  546 
Hemorrhage,  heart  wounds,  546,  550 

meningeal,  45 

subdural,  48 

in  thymus,  534 

in  thyroid,  485 

tongue,  197 

venous  sinuses,  skull,  49 
Hemostasis,  excision  jaw,  179 

excision  tongue,  219 

heart,  551 

in  trephining,  65 
Henle's  spine,  309 
Hermann.     Fractured  skull,  24 


INDEX 


639 


Hernia  cerebri,  58 
Hertzler.     Tumors,  scalp,  11,  20 
Hilton's  law,  361 
His.     Development,  79,  83 
Histology,  thymus,  529 
Holz-phlegmon,  340 
Hodgkin's  disease,  336,  344 
Holmes.     Naso-pharyngoscope,  278 
Horn,  cutaneous,  13,  155 
Horsley,  Shelton.     Suture  recurrent  laryn- 
geal nerve,  358 
Hoffmann's  test,  524 
Huguier.     Ankylosis  Jaw,  127 
Hydatid  cysts  tongue,  226 
Hydatids,  muscles  neck,  388 
Hygroma  neck,  302 
Hyperemia,  Bier's  breast,  565 

thymus,  534 
Hyperkeratosis,  nasopharj-nx,  270 
Hyperplasia,  thymus,  535 
Hyperthymization,  536 
Hyperthyroidism,  498 

Hypertrophy,  faucial  and  pharyngeal  lym- 
phoid tissue,  241 

thymus,  538 

turbinate  bone,  256 
Hypoglossal  nerve,  injury,  357 
Hypoparathyroidsm,  511 
Hypothyroidism,  excision,  tumors,  thyreo- 
glossal  duct,  116 

I 

Ignipuncture,  angioma,  15 

Incision  tympanum,  300 

Indications,  removal,  tumors,  breast,  561 

operations,  breast,  618 
Induration,  breasts,  562,  564,  567 
Infants,  fracture,  skull,  27 
Infantile  hypertrophy,  breast,  559 
Infection,  breast,  563 
Infections  of  face,  133 

intracranial,  59 

larynx  and  trachea,  420 

middle  ear,  299 

nasopharynx,  270 

neck,  321 

oesophagus,  471 

pericardium,  552,  555 

pharynx,  239 

salivary  glands,  230 

scalp  wounds,  9 

thymus,  534 


Infective  myositis,  neck,  386 

Inferior  maxillary  nerve,  injections,  173 

Inflammations,  acute,  neck,  321 

chronic,  neck,  325 

larynx,  420 

mastoid,  acute,  307 
chronic,  308 

middle-ear,  299 

thymus,  534 

tongue,  199 
Influenza,  nose,  261 
Injections,  alcohol,  angioma,  face,  139 

angioma,  tongue,  212 

boiling  water,  angioma,  153 

neuralgia,  167,  173 

paraflin,  nose,  251 
Injury,  brachial  plexus,  361 

nerves,  neck,  357 
Injuries,  cervical  plexus,  359 

cranial  nerves,  ^ 

face,  117  ^ 

heart,  545 

jaws,  117 

larynx,  417 

mouth,  195 

muscles,  neck,  388 

naso-pharynx,  269 

neck,  352 

oesophagus,  462 

pia  mater,  51 

trachea,  419 

salivary  glands,  227 

skull  and  contents,  23 
Innominate  aneurism,  374 
Inoperable  cancer,  tongue,  225 
Insanity,  traumatic,  62 
Instruments,    direct   laryngoscopy,    401    el 
seq. 

gastroscopy,  451 

oesophagoscopy,  451 
Insuflflation  anesthesia,  408,  431,  547 
Interdental  splints,  120,  124 
Intermaxillary  bone,  81 
Intracanalicular  my.xoma,  breast,  597,  599 
Intracranial  aneurism,  378 

complications,  middle  ear  disease,  317 

infections,  59 
Intrathoracic  goiter,  507 
Intratracheal  insufflation,  547 
Intubation,  larynx,  420 
Involution,  abnormal,  breast,  606 
lodin,  thyroid,  478 


640 


INDEX 


Jackson's  cannula,  440,  441,  447 
Jacksonian  convulsions,  54 
Jackson,  Ch.     OEsophagoscope,  451 
Sarcoma,  lar3'nx,  427 
Thyrotomy,  428 
Tracheotomy,  thymus,  542 
Jacobson.     Middle  meningeal  hemorrhage, 

46 
Janeway.     Anesthesia,  430 
Janeway,  H.     Operation,  oesophagus,  472 
Jaws,  development,  80 

injuries  and  diseases,  117 
actinomycosis,  155 
ankylosis,  125 
dislocation,  129 
lower,  117 

dislocation,  129 
fracture,  117 
repair,  119 
treatment,  119 
operations  on,  177-193 
osteomyelitis,  156 
periostitis,  157 
phosphorus  necrosis,  159 
pyorrhea  alveolaris,  158 
Rigg's  disease,  158 
syphilis,  158 
tuberculosis,  156 
tumors,  159-177 
upper,  fractures,  123 
treatment,  124 
Johnson.     Development,  72,  76 
Johnston.     Direct  laryngoscopy,  403 
Joint,  temporo-maxillary,  125 

K 

Kaufman.     Salivary  fistula,  229 
Keen.     Tumors,  carotid  body,  399 
Keiller.     Hodgkin's  disease,  345 

Lymphatics, 
Kelly.     Stenosis,  oesophagus,  463 
Keloid  scar,  13 

Killian's  operation,  frontal  sinus,  285 
Kingsley's  splint,  120 
Klose.     Treatment,  thymus,  542 
Klurapke.     Paralysis,  364 
Kocher.     Brain  pressure,  40 

Facial  paralysis,  170 
Kocher's  sign,  exophthalmic  goiter,  490 
Konig,  F.     Branchial  fistulae,  113,  114 


Konig,  F.     Excision,  jaw,  179,  182 

Hare-lip,  90 

Thymectomy,  542 
Konig-Miiller.     Operation,  skull,  37 
Koppen.     Dementia,  64 
Korbe.     Facial  paralysis,  170 
Korsakow's  psychosis,  63 
Kredl's.     Hemostatic  bars,  65 
Krogius.     Treatment,  angioma,  16 
Kronlein.     Excision,  jaw,  179 
Kiittner.     Lymphatics,  neck,  330 


Laceration,  brain,  51 

Lachrymal  glands,  Mikulicz  disease,  233 

Landry.     Fracture,  jaw,  121 

Lane,  Sir  W.  A.     Cleft  palate,  operation, 

98  ef  seq. 
Langenbeck,  von.     Salivary  fistula,  229 

Uranoplasty,  102 
Laryngeal  symptoms,  goiter,  506 
Laryngectomy,  432 
Laryngoscopy  and  bronchoscopy,  401 

anesthesia,  402,  407,  408 

bronchoscopy,  409 

instruments,  401  et  seq. 
Laryngostomy,  444 
Laryngotomy.     Butlin's,  180 

excision,  tongue,  219 
Laryngofissure,  424 
Laryngospasm,  parathyroid,  523 
Larynx, 

deformities,  439 

foreign  bodies,  410 

fractures,  418 

infections,  420 

injuries,  417 

intubation,  420 

laryngectomy,  432 

laryngostomy,  444 

leprosy,  422 

operations,  external,  430 

scleroma,  422 

stenosis,  420,  441 

syphilis,  421 

thyrotomy,  427-431 

tuberculosis,  421 

tumors,  423,  426 

typhoid,  422 

voice  after  operation,  cancer,  429 

wounds,  418 
Lateral  pharyngotomy,  248 


INDEX 


641 


Law,  Aran's,  fractured  skull,  25 

Hilton's,  361 
Leaf,  lymphatics,  neck,  330 
Lenormant.    Lymph  glands,  face,  135 
Leprosy,  nose,  265 
Leptomeningitis,  58 
Lesions,  breast,  557 
Leucoplakia,  cheek,  palate,  190 

tongue,  201,  215 
Levy.     Injections,  nerves,  173 
Ligation,  common  carotid,  377 

external  carotid  artery,  179,  219 

innominate  artery,  374 

thoracic  duct,  357 

vessels,  exophthalmic  goiter,  491 
Ligneous  abscess,  neck,  340 
Lillie.     Development,  72 
Lingual  quinsy,  201 
Lip,  carcinoma,  147 

development,  80 

excision,  150 

hare-,  87 

infections,  133 

lower,  cleft,  fistula,  in 
Lipoma,  face,  154 

mouth,  191 

neck,  390 

scalp,  12 
Little's  disease,  56 
Liver,  Hodgkin's  disease,  347 
Longcope.     Hodgkin's  disease,  346 
Lower  jaw,  excision,  178 
Ludwig's  angina,  186,  322 
Lumbar  puncture  in  subdural  hemorrhage, 

55 
Lumpy  jaw,  155  ' 

Lung,  heart,  wounds,  550 
Lupus,  scalp,  II 

tongue,  204 
Luschka.     Carotid  gland,  397 
Luschka's  bursa,  273 
Lutelle.     Thymus,  540 
Luys.     Intracranial  hemorrhage,  50 
Lymphadenoma,  344 
Lymphangioma,  face,  154 

mouth,  191 

neck,  397 

tongue,  212 
Lymph  glands,  face,  135 
Lymphatics,  breast,  576,  627 

larynx,  428 

lip,  epithelioma,  149 

41 


Lymphatics,  neck,  325 

scalp,  3 

tongue,  217,  220 
Lymphoid  tissues,  faucial,  hyper trophied, 

241 
Lymphoma,  malignant,  344 
Lymphosarcoma,  neck,  341 

M 

MacCallum.     Hodgkin's  disease,  349 

tetany,  511,  525 
MacCarty.    Thyroid,  488 
Macewen.     Needling  aneurism,  375,  380 

pupil,  44 
Macewen's  triangle,  310 
McBride.     Angioma,  15 
McGarrison.     Goiter,  505 
McGuire.     Thymus,  539 
McMurrich.     Development,  69,  76 
Macrogloss'a,  213 
Macrostoma,  no 
Madelung.     Dififuse  lipoma,  391 
Magnets,  foreign  bodies,  bronchi,  417 
Maitland's  excision,  cancer,  mouth,  193 

tongue,  223 
Malar  bone,  fracture,  124 
Malgaigne's  operation,  hare-lip,  91 
Malignant  cyst,  breast,  584,  615 

disease,  breast,  558  et  seq. 
oesophagus,  472 

lymphoma,  344 

pustule,  134 

tumors,  larynx,  426 
thyroid,  509 

warts,  lip,  148 
Mamma  diseases.     See  Breast,  557 
Mammectomy,  620,  622 
Mandibular  arch,  80 

tubercles,  no 
Mascagni.    Lymph  glands,  face,  135 
Mastitis,  SS7,  S64,  567,  s8o 

chronic  lactation,  abscess,  594 
Mastoiditis,  acute,  306 

chronic,  308 
Matas.     Diseases,  vessels,  372 
Matas'  splint,  121 

treatment,  aneurism,  374, 377, 378, 380, 
3S6 
Matthews.     Voice  after  operation,  goiter, 

506 
Ma.xillary  nerve,  inferior,  injection,  173 
superior,  injection,  173 


642 


INDEX 


Mayo,  C.  H.     Cleft  palate,  104 

Hare-lip,  91 
Median  cysts,  fistula  neck,  115 
Mediastinal  adhesive  pericarditis,  553 

emphysema,  420 
Medullary  carcinoma,  breast,  616 
Melano-sarcoma,  face,  139 
Melanoma  scalp,  13 
Meltzer-Auer.     Anesthesia,  430 
jMembrana  tympani  incisions,  300 
Meningeal  artery,  middle,  67 
Meningitis,  9,  58,  ei  seq.,  320 

infections,  face,  133 
Meningeal  hemorrhages,  45 
Meningocele  spuria,  7 
Messerer.     Fracture  skull,  23,  et  seq. 
Methods  anesthesia  operations,  heart,  etc., 

547 
Microstoma,  no 

Mieremet.     Hodgkin's  disease,  351 
Mikulicz  disease,  233 
Mikulicz.     Rib  spreader,  549 
Mixter.     (Esophagus,  466 
Mixed  tumors,  salivary  glands,  234,  236 
Moebius.     Treatment  goiter,  490 
Moles,  scalp,  13 
Moore.     Aneurism,  375 
Morgagni.     Exophthalmic  goiter,  475 
Mortality,  excision  breast,  630 

tongue,  225 
Mosher.     Direct  laryngoscopy,  403,  411 

Forceps,  457 

(Esophagoscope,  451 
Mott.     Psychasthenia,  63 
Mouth.     See  Buccal  cavity,  183 

deformities  of,  no 
Mucocele  nose,  268 

orbit,  144 
Mucous  cysts,  mouth,  195 
Much.     Hodgkin's  disease,  351 
Murphy,  J.  B.     Ankylosis  jaws,  126  el  seq. 

Injection  nerves,  173 
Muscles,  neck,  diseases,  386 
Myositis,  neck,  386 

ossificans,  neck,  387 
Myringotomy,  300 
Myxoma,  breast,  597,  599 

N 

Nsevus  neck,  396 
Nasopharynx,  adenoids,  270 
infections,  270 


Nasopharymx,  injuries,  269 

Tornwaldt's  disease,  273 

tumors,  273 
Naso-pharyngoscope,  278 
Neck,  actinomycosis,  339 

air  embolism,  355 

aneurism,  373 

arteries,  diseases,  372 
injuries  to,  353,  368 

carotid  gland,  397 

dissection,  cancer  breast,  629 

Hodgkin's  disease,  344 

inflammations,  acute,  321 
chronic,  325 

injuries,  352,  388 

ligneous  abscess,  340 

Ludwig's  angina,  322 

lymphatics,  325 

lymphosarcoma,  341 

muscles,  diseases  of,  386 

neoplasms,  390 

nerves,  injuries  to,  357 

thoracic  duct,  356 

tuberculosis,  adenitis,  333 

tumors,  390 

wounds,  352,  388 

veins,  injuries  to,  355 
Necrosis,  middle-ear,  304 

phosphorus  jaws,  159 

skull,  9 
Needles,  Deschamp's,  105 
Needling  aneurism,  375 
Negri.     Hodgkin's  disease,  351 
Nelaton's  operation,  hare-lip,  91 
Neoplasms,  benign  breast,  581 

neck,  390 

pharynx,  246 

salivary  glands,  233 

scalp,  n 

thymus,  534,  540 

tongue,  211 
Nerve,  facial  anastomosis,  169 

glossopharyngeal,  injury,  357 

hypoglossal,  injury,  357 

inferior  dental,  175 

maxillary  injection,  1 73 

lingual,  17s 

phrenic,  361 

pneumogastric,  injury,  357 

recurrent  laryngeal  goiter,  506 
suture,  358 

spinal  accessory,  injury,  359 


INDEX 


643 


Nerve,  superior  maxillary,  1 74 

supra-orbital,  174 

suture,  neck,  358 

sympathetic,  neck,  358 

trifacial  operations  on,  174 
Nerves,  brachial  plexus,  injury,  361 

cervical  plexus,  injuries,  359 

cranial,  injuries,  ^:i 
Nervorum  elephantiasis,  13 
Neuralgia,  trifacial,  165,  173 
Neurasthenia  traumatic,  62 
Neurectomy,  trifacial  nerve,  174 
Neuroma  plexiform,  13 
Nevi  pigmented  scalp,  13 
Nevus  face,  139,  153 

mouth,  191 

telangiectatic,  14 

tongue,  211 
Nicoladini.     Ankylosis,  jaw,  127 
Nipple,  bleeding,  571 

care  of,  565 

retracted,  572 

ulceration,  573 
Noma,  185 
Nose,  accessory  sinuses,  274 

actinomycosis,  265 

adhesions,  260 

antrum,  281 

atresia,  260 

deformities  of,  107 
external,  249 
internal,  254 

development,  80 

deviated  septum,  254 

fracture,  122 

frontal  sinusitis,  284 

glandus,  265 

infections,  260 

Killian's  operation   285 

leprosy,  265 

methods  examination,  278 

paraffin  injections,  251 

perforated  septum,  260 

saddle  nose,  250 

scleroma,  265 

sinusitis,  275 

sphenoidal  sinus,  288 

syphilis,  263 

tuberculosis,  262 

turiiors,  266 

turbinates  enlarged,  2>A 


O 


Ocular  symptoms,  goiter,  490 
Odontoma,  164 
O'Dwyer.     Intubation,  420 
(Edema,  glottidis,  198 

larynx,  420 
CEsophagoscopy,  451 

burns,  462 

cardiospasm,  464 

deformities,  463 

diverticulum,  467 

foreign  bodies,  457 

infections,  471 

injuries,  462 

oesophagismus,  464 

cesophagotomy,  469 

scalds,  462 

stenosis,  463,  465 

syphilis,  471 

tracheo-cesophageal,  fistula,  465 

tuberculosis,  471 

tumors,  472 
(Esophagismus,  464 
(Esophagitis,  466 
(Esophagotomy,  469 
(Esophagus,  451 
Olfactory  nerves,  injuries,  S3 
Oliver.     Thymus,  542 
Operation,  abscess  brain,  318 

anastomosis  facial  nerve,  1 70 

ankylosis  jaw,  126 

arterio-venous  aneurism,  384 
Operations,  branchial  cysts  and  fistulae,  114 

breast  indications,  618 

cancer,  cheek  and  mouth,  193 
larynx,  427 
oesophagus,  472 

carotid  aneurism,  376 

cervical  adenitis,  337 

cleft  palate,  90 

diaphragm,  555 

diverticulum  oesophagus,  469 

epithelioma,  lip,  148 

exophthalmic  goiter,  491 

exploratory^  breast,  582,  619 

external,  larynx,  430 

for  adenoids,  272 

for  lingual  cancer,  223 

for  middle  meningeal  hemorrhage,  49 

for  nasal  deformities,  249  cl  scq. 


644 


INDEX 


Operations,  for  neuralgia,  167,  173 

for  sinusitis,  281 

Grant's,  excision  lip,  150 

hare-lip,  90 

heart,  547 

Killian's,  2 85 

non-toxic  goiter,  406 

on  mastoid,  309 

on  the  jaws,  177 

on  thjToid,  493 

pericardium,  547 

salivar}'  fistula,  229 

thymus,  542 

tonsillectomy,  243 
Operculum,  neck,  79 
Optic  discs,  in  compression,  brain,  43 
Optic  nerves,  injuries,  34 
Orbit  abscess,  142 

aneurism,  146 

punctures,  28 

tumors,  144 

wounds  of,  141 
Os  incisivum.  Si 

Osmic  acid,  injection,  nerves,  173 
Ossicles,  ear,  necrosis,  304 
Osteoma,  nose,  268 
Osteoma,  orbit,  146 
Osteomyelitis,  jaws,  156 

skull,  9 
Osteoplastic  exposure,  heart,  549 

repair,  skull,  37 
Ot-haematoma,  294 
Otitis  media,  299 
Otorrhcea,  307 


Pachydermia,  larynx,  423 
Pachymeningitis,  59 
Paget.     Cyst,  neck,  393 
Paget's  disease,  nipple,  573 
Pain,  breast  lesions,  570 
Palate,  development  of,  81 
Paltauf.     Hodgkin's  disease,  349 
Papillomatous  cysts,  breast,  584,  591,  615 
Papilloma,  larynx,  424 

mouth,  191 

nose,  267 

oesophagus,  472 

scalp,  13 

tongue,  211 
Paracentesis,  ear,  300 
Parafhn  injections,  nose,  251 


Paralysis  agitans  and  parathyroids,  511 

Erb-Duchenne,  363 

facial,  168 

general,  insane,  64 

Klumpke's,  364 

laryngeal  nerve,  goiter,  506 

middle  meningeal  hemorrhage,  47 

muscles,  neck,  386 

posterior,  operation,  365 
Paralytic  stenosis,  larynx,  442 
Paraplegia,  spastic,  56 
Parathyroids,  511,  498 

accessory,  514 

anatomy,  512 

chromaflBn  system,  522 

embryology,  512 

histology,  517 

hyperparathyroidism,  512 

hypoparathyroidism,  511 

pathology,  522 

physiology,  519 

summary,  526 

symptoms,  tetany,  522 

tetany,  519 

treatment  tetany,  524 

tumors,  522 
Park.     Thj^mus,  539 
Parotid.     See  Salivary  glands. 

excision,  236 

gland,  injuries,  227 
Parotitis,  230 
Parry.     Goiter,  475 
Pathology,  parathyroids,  522 
Patrick.     Injections,  nerves,  173 
Patterson,  Ellen  J.     Radium,  larynx,  427 
Patterson.     Tracheotomy,  446,  450 
Peck.     Drainage,  heart  wounds,  552 
Pedrazzini,  chondrotomy,  542 
Percussion  of  skull,  31 
Perforations,  membrana  tympani,  305 
Perforated  nasal  septum,  260 
Pericardium,  545 

adhesive  mediastinal  pericarditis,  553, 

aspiration,  555 

cardiolysis,  553 

drainage,  552 

effusions,  554 

hemopericardium,  546 

infections,  552 

injuries,  545 

operation  on,  549 

osteoplastic  exposure,  549 


INDEX 


645 


Pericardium,  pericarditis,  553 

pericardiotomy,  550 

pleural  drain,  552 

purulent  exudates,  555 

symptoms,  adhesive  pericarditis,  553 

treatment,  wounds,  547 

tuberculosis,  555 

wounds,  545 
Perichondritis,  larynx,  420 
Periosteal  sarcoma,  jaws,  159 
Periostitis,  jaws,  157 
Peritonsillar  abscess,  240 
Pharyngeal  diverticula,  113 

tonsil,  270 
Pharyngotomy,  247 
Pharynx,  inflammation,  239 

lateral  pharyngotomy,  248 

Ij'mphoid  tissue,  hypertrophied,  241 

neoplasms,  246 

peritonsillar  abscess,  240 

pharyngotomy,  247 

subhyoid  pharyngotomy,  247 

tonsils,  enlargement  of,  242 

tonsillectomy,  243 

tonsillitis,  242 

tuberculosis,  241 

tumors,  246 
Phelps.     Intracranial  hemorrhage,  50 
Phlegmon  ligneuse,  340 
Phosphorus  necrosis,  jaws,  159 
Phrenic  nerve,  injuries,  361 
Physiology,  thymus,  531 
Pia  mater,  injuries,  51 
Pilcher,  injury,  vagus,  358 
Plates  in  skull  defects,  37 
Pleural  drain,  wounds,  pericarditis,  552 
Plexiform  angioma,  15 

neuroma,  13 
Plexus,  brachial,  injury,  361 

cervical,  injuries,  359 
Plummer.     Exophthalmic  goiter,  488 

CEsophagus,  466 

Toxic  goiter,  500 
Pneumatocele  cranii,  6 
Pneumogastric  nerve,  injury,  357 
Pneumothorax,  548 
Polypi,  ear,  304 

larj-nx,  423 

nose,  266 
Port  wine  stain,  scalp,  14 
Position,  Rose's,  96 
Postural  paralysis,  365 


Posture  patient,  cesophagoscopy,  452 
Post-operative  hemorrhage,  tonsillectomy, 
245 

paralyses,  365 

parotitis,  230 
Pott's  puffy  tumor,  60,  61 
Precancerous  lesions,  tongue,  214 
Pregnane}',  breasts,  563 
Prenant.     Development,  79 
Pressure,  differential,  547 
Prognosis,  adenoids,  271 

compression,  brain,  45 

fractured  skull,  35 

gunshot  wounds,  skuU,  39 

hemorrhage,  venous  sinus,  skull,  50 

Hodgkin's  disease,  351 

middle  meningeal  hemorrhage,  48 

sarcoma,  jaws,  160 

tubercular  adenitis,  336 
Psychasthenia,  62 
Psychosis,  Korsakow's,  63 
Pulsating  exophthalmos,  57     . 
Pulse,  injury,  vagus,  358 

in  middle  meningeal  hemorrhage,  47 
Punctures,  skull,  28 
Pupil,  Macewen,  44 
Pusey.     Moles,  scalp,  13 
Pustule,  malignant,  134 
Pyemic  endarteritis,  372 
Pyorrhoea  alveolaris,  158 

salivalis,  232 


Quins}',  lingual,  201 

R 

Radical  mastoid  operation,  313 
Radium,  cancer,  larj-nx,  427 
oesophagus,  473 

tumors,  face,  146,  152 
Ransohoff.     Median  hare-lip,  108 
Ranula,  238 

Rash.     Wandering  tongue,  209 
Reclus'  disease,  606 
Recurrent  laryngeal  nerve,  suture,  358 
Rectus,  phlegmoni  ligneuse,  340 
Rehn.     Pericarditis,  552 
Reich's  operation,  complicated  hare-lip,  95 
Removal,  adenoids,  272 

foreign  bodies,  larynx,  410 
Repair,  fracture,  nose,  252 
Replantation  bone,  fracture,  skull,  36 


646 


INDEX 


Resection,  septum  nasi,  255 
Respiratory  disturbance,  thymus,  543 
Results  excision,  breast,  630 

operation,  cervical  adenitis,  338 
Rhinoplasty,  252 
Rib,  cervical,  365 

spreader,  549 
Riedel.     Injury,  phrenic  nerve,  361 
Rigg's  disease,  158 

Rizzoli-Esmarch.     Ankylosis  jaw,  128 
Rodent  ulcer,  151 
Rogers.     Parathyroids,  514 
Roger's  serum,  491 
Rolando.     Fissure,  67 
Rosenow.     Hodgkin's  disease,  352 
Rose's  position,  96 
Rubber  tissue  in  skull  defects,  37 
RUdinger.     Treatment,  goiter,  490 
Ruptured^heart,  550 


Saddle  nose,  250 
Salivary  calculi,  231 

glands,  227 

actinomycosis,  233 

calculi,  231 

excision  glands,  235 

fistulse,  228 

infections,  230 

injuries,  227 

Mikulicz.     Disease,  233 

Stenson's  duct,  wounds,  228 

syphilis,  233 

tuberculosis,  233 

tumors,  233 

wounds,  227 
Sandstrom.     Parathyroids,  511 
Sarcoma,  breast,  562,  584,  618,  625 
age,  patients,  558 

face,  139,  152 

jaws,  159 

larynx,  426 

mouth,  192 

muscles,  neck,  389. 

nose,  268 

oesophagus,  472 

pharynx,  246 

scalp,  13,  19 

thyroid,  509 

tongue,  214 
Sauerbruch.     Heart,  551 

Rib  spreader,  549 


Savariaud.    Aneurism,  380 
Scalds,  mouth,  196 
oesophagus,  462 
tongue,  198 
Scalp  abscess,  pericranial,  10 
anatomy,  i 
caput  succedaneum,  5 
cephal-hematoma,  5,  6 
complications,  wounds,  9 
contusions,  3 
cystic  tumors,  7 
dangerous  area,  2 
diseases  of,  alopecia  syphilitica,  11 
aneurism,  19 
cirsoid,  15 
angioma  cavernosum,  15 
racemose,  15 
simplex,  14 
athpromata,  12 
carbuncles,  11 
cutaneous  horn,  13 
cysts,  dermoid,  12 

subaceous,  12 
elephantiasis  nervorum,  13 
endothelioma,  20 
epithelioma,  12,  13,  21 
fibroma  moUuscum,  13 
furuncles,  11 
gummata,  11 
horn,  cutaneous,  13 
keloid,  13 
lipoma,  12 

lupus,   II 

melanoma,  13 
moles,  13 
neoplasms,  11 
neuroma  plexiform,  13 
nevus  Lelang,  14 
papilloma,  13 
pigmented  nevi,  13 
plexiform  neuroma,  13 
sarcoma,  13,  19 
syphilis,  11 
treatment,  angiomata,  15 

moles,  13 

nevi,  IS 
tuberculous  ulcers,  11 
tumors,  II 
ulcers,  tubercular,  n 
warts,  13 
wens,  12 
X-ray,  moles,  13 


INDEX 


647 


Scalp,  emissary  veins,  3 

erysipelas,  10 

hematoma,  2-4 

infections,  wounds,  9 

lymphatics,  3 

meningocele  spuria,  7 

pneumatocele,  6 

scalping,  2 

sinus  pericranii,  7 

traumata,  i 

treatment,  wounds,  8 

vascular  supply,  2 

wounds,  3,  7 
Scalvo's  serum,  135 
Scapula,  winged,  359 
Scar,  keloid,  13 
Scars,  depressed  face,  132 
Schimmelbusch's  disease,  606 
Schlange.     Excision  alveolus,  177 
Schroeder.     Suture  phrenic  nerve,  361 
Scirrhus  of  parotid,  234 
Scleroma,  nose,  265 
Schwalbe.     Development,  ear,  83 
Schwartze's  operation,  309 
Sebaceous  cysts,  scalp,  12 
Sebilean,  fracture  jaw,  121 
Semen.     Cancer,  larynx,  427,  428 
Septum  nasi,  deformities,  254 
Septum  nose,  abscess,  260 
Serum,  Scalvo's,  135 
Serum  treatment,  goiter,  490 
Sherren.     Injury  nerves,  neck,  357, 358, 359, 

361,  365 
Sialo-adenitis,  230 
Signs,  eye,  goiter,  490 
Singer's  nodules,  larynx,  423 
Sinuses,  lip,  108 

lower  lip,  112 

nose,  274 

venous,  skull,  hemorrhage,  49 
Sinusitis,  275 
Sinus  pericranii,  7,  51 

precervical,  79 

thrombosis,  60,  317 
Sippey.     (Esophagus,  466 
Skull,  23 

Skull  and  brain,  artery,  middle  meningeal,  45 
exposure,  49 

anatomy,  23 

basal  fracture,  25,  41 

bleeding,  meningeal  artery,  45 

coma,  differential  diagnosis,  44 


Skull  and  brain,  complications,  fracture,  45 
compression,  41 

treatment,  45 
concussion,  39 
contre-coup,  fracture,  27 
cranial  nerves,  injury,  33 
diagnosis,  compression,  44 

differential,  coma,  44 

fracture,  30 
defects  in,  repair,  36,  37 

middle  meningeal,  hemorrhage,  48 
elasticity  skull,  23 
emphysema,  ^^ 
exophthalmos,  pulsating,  57 
fissure  fracture,  29 
fractures,  23 

types  of,  28 
gunshot  wounds,  37 
hemorrhage,  meningeal,"  45 

subdural,  48,  50,  52,  55 

venous  sinuses,  49 
infants,  fracture,  27 
injuries,  cranial  nerves,  33 
laceration,  brain,  51 
lumbar  puncture,  55 
Macewen  pupil,  44 
mechanics  of,  23 
meningeal  hemorrhage  45 
middle  meningeal  hemorrhage,  45 
nerves,  cranial,  injuries,  33 
operation,    middle    meningeal   hemor- 
rhage, 49 
osteoplastic  repair,  37 
paralysis  in  middle  meningeal  hemor- 
rhage, 417 
percussion  of  skull,  31 
pia  mater,  51 
pot-lid  fracture,  25 
prognosis,  compression,  45 

fracture,  35 

gunshot  wounds,  39 

hemorrhage,  venous,  sinus,  50 

middle  meningeal  hemorrhage,  48 
punctures,  28 
pupil,  Macewen,  44 
replantation  fragments,  bone,  36 
sinus,  pericranii,  51 

venous,  hemorrhage,  49 
subdural  hemorrhage,  48,  50,  52 
symptoms,  fracture,  30 

compression,  43 

concussion,  39 


648 


INDEX 


Skull  and  brain,   symptoms,  injuries,  cra- 
nial nerves,  34  et  scq. 
laceration,  brain,  53 
middle  meningeal  hemorrhage,  46 
treatment,  compression,  45 
concussion,  41 
fractures,  36 

gunshot,  skull  and  brain,  39 
hemorrhage,  venous,  sinus,  50 
middle  meningeal  hemorrhage,  48 
subdural  hemorrhage,  55 
trephining,  middle    meningeal   hemor- 
rhage, 49 
vault,  fractures,  30 
venous  sinuses,  hemorrhage,  49 
wounds,  27-37 
of  brain,  57 
SkuU  infections,  9 
Smoker's  tongue,  202,  215 
Smooth  tongue,  210 
Snow,  carbon-dioxide,  13 
Spasmodic  ankjdosis,  jaw,  125 
stenosis,  oesophagus,  464 
Spastic  paraplegia,  56 
Sphenoidal  sinuses,  276,  288 
Spiller.     Facial  paralysis,  1 70 
Spinal  accessory  nerve,  injury,  359 
Spleen.     Hodgkin's  disease,  349 
Splints,  interdental,  120,  124 
Stacke's  protector,  314 
Statistics,  exophthalmic  goiter,  499 
operation,  goiter,  508 
wounds,  heart,  545 
Status  lymphaticus,  536 

thymicus,  534 
Stellwag's  sign,  490 
Stenosis,  bronchi,  439 
larynx,  420,  441 
oesophagus,  463,  465 
trachea,  439 
Stenson's  duct,  injuries,  228 
Sternberg.     Hodgkin's  disease,  349 
Sterno-mastoid,  atrophy,  386 
muscle,  excision,  222,  224 
Stieda.     Development,  in 
Stings,  insects,  tongue,  199 
Stomatitis,  183 

Stromeyer,  sinus  pericranium,  7,  51 
Subclavian  artery,  injuries,  371 
Subdural  hemorrhage,  48,  50,  52,  55 
Subhyoid  pharyngotomy,  247 


Sublingual  gland,  excision,  235 
Submaxillary  cellulitis,  322 

gland,  excision,  235 
Submucous  resection,  septum,  nose,  255 
Substernal  goiter,  507 
Superior  maxillarj^  nerve,  injection,  173 
Supraclavicular  glands,  cancer,  breast,  629 
Suprameatal  triangle,  310 
Suture,  heart,  550 

in  hare-lip,  96 

phrenic  nerve,  361 

recurrent  laryngeal  nerve,  358 

thorax,  553 
Sylvian  fissure,  67 

S3Tnpathectomy,  exophthalmos,  499 
Sympathetic  nerve,  neck,  injury,  358 
Symptoms,  adenoids,  271 

acute  mastoiditis,  307 

adhesive  pericardium,  553 

brain  abscess,  318 

bullet  wounds,  neck,  353 

chronic  mastoiditis,  309 

concussion,  brain,  39 

division,  spinal  accessory  nerve,  359 

fracture,  skull,  30 

heart  wounds,  546 

Hodgkin's  disease,  347 

injury,  brachial  plexus,  362 

injuries,  cranial  nerves,  34  et  seq. 
nerves,  neck,  357  et  seq. 

laceration,  brain,  53 

lesions,  breast,  570 

meningitis,  59 

middle  meningeal  hemorrhage,  46 

salivary  calculi,  232 

sinusitis,  276 

tetany,  522 

toxic,  goiter,  500 
Syphilis,  jaws,  158 

larynx,  421 

lip,  148 

muscles,  neck,  388 

nose,  263 

oesophagus,  471 

of  mouth,  188 

pharynx,  241 

salivary  glands,  233 

scalp,  II 

tongue,  206 

trachea,  421 
Syringe,  ear,  296 


INDEX 


649 


Taylor.     Brachial  plexus,  363 
Temporo-sphenoidal  abscess,  319 
Tetanus  in  face  wounds,  131 
Tetany,  498,  519 

Thompson,  J.  E.     Operation,  hare-lip,  92 
Thomson,  St.  Clair.     Amputation,  epiglot- 
tis, 427 

Thyrotomy,  428 
Thoracic  duct,  wounds,  356 
Thorax,  cardiolysis,  553 

operation,  heart,  549 
Thrombosis,  sinus,  60,  317 
Thymus,  529 

abscess,  Dubois,  534 

absence,  532,  534 

Addison's  disease,  536 

anatomy,  531 

blood  examination,  539 

diagnosis,  539 

embrj-ology,  529 

exophthalmic  goiter,  536,  538 

histology,  529 

hyperplasia,  535 

hypertrophy,  538 

in  goiter,  498 

operations  on,  542 

pathology,  534 

physiology,  531 

status  lymphaticus,  536 
thj-micus,  534 

summary,  543 

thymectomy,  542 

thymic  death,  529 

thymopriva,  532    . 

treatment,  thymus,  541 

tumors,  534,  540 
Thymic  tracheostenosis,  440 
Thyreo-glossal  duct,  78,  225 
fistula  and  cysts,  115 
Thyroid,  475 

accessory,  116 

adenoma,  486,  508 

anatomy,  475 

anomalies,  477 

carcinoma,  509 

development,  476 

exophthalmic  goiter,  488 

eye  symptoms,  goiter,  490 

histologic  conditions,  487 

intrathoracic  goiter,  507 


Thyroid,  ligation,  vessels,  491,  493 
malignant  tumors,  509 
non-toxic  goiter,  503 
operations,  exophthalmic  goiter,  491, 

493 
non-to.xic  goiter,  506 

parath5Toids,  498 

pathology,  480,  501,  505 

physiology,  477 

sarcoma,  509 

statistics,  exophthalmic  goiter,  499 

substernal  goiter,  507 

tetany,  498 

thyroidectomy,  493 

thyroiditis,  485 

thyrotomy,  424,  427,  431 

toxic  goiter,  48S 

toxic  non-exophthalmic  goiter,  500 

treatment,  exophthalmic  goiter,  490 

tumors,  tongue,  225 

varieties,  goiter,  485 
Thyrotoxicosis,  488 
Tic  douloureux,  166,  173 
Tilley.     Thyrotomj^  428 
Tongue,  black,  210 

burns,  198 

development,  77 

excision,  217  e/  seq. 

foreign  bodies  in,  198 

gangrene,  201 

glossodj-nia  exfoliativa,  210 

inflammations,  199 

leucoplakia,  201,  215 

lingual  quinsy,  201 

lupus,  204 

IjTnphatics,  220 

macroglossia,  213 

precancerous  lesions.  214 

smoker's  patch,  202 

smooth  tongue,  210 

stings,  199 

syphilis,  206 

tuberculosis,  204 

tumors,  211 

ulceration,  203 

wandering  rash,  209 

wounds,  197 
Tonsillar  abscess,  240 

gland,  lymph,  330 

tonsillitis,  242 
Tonsillectomy,  242  ct  seq. 
Tonsillotomy,  242 


650 


INDEX 


Tonsils,  enlargement  of,  242 
Topography,  cerebral,  65 
Tornwaldt's  disease,  273 
Torticollis,  386 
Toxic  goiters,  485 

non-exophthalmic  goiter,  500 
Trachea,  411 

deformities,  439 

foreign  bodies,  411 

infections,  420 

injuries,  419 

scleroma,  422 

stenosis,  439 

sjTDhilis,  421 

tracheotomy^  420 

tuberculosis,  421 
Tracheo-oesophageal  fistula,  463 
Tracheotomj',  420,  441,  446 
Transillumination,  nose,  279 
Transplantation,   cartilage  or  bone,  nose, 
252 

fat,  scars,  face,  132 
Trauma,  breast,  562 
Traumata,  pharynx,  239 

scalp,  I 

skull  and  contents,  23 
Traumatic  dementia,  64 
Treadel.     Face  adenitis,  137 
Treatment,  actinomycosis,   138,  156,   190, 
340 

acute  inflammation,  pharynx,  240 

adenoids,  272 

angioma,  face,  139 
tongue,  212 

ankylosis,  jaw,  126 

anthrax,  135 

arterio-venous  aneurism,  neck,  384. 

cancer,  mouth  and  cheek,  193 
oesophagus,  472 
tongue,  218 

carotid  aneurism,  375,  378,  379 

compression,  brain,  45 

concussion,  brain,  41 

depressed  scars,  face,  132 

dislocation,  jaw,  129 

epithehoma,  lip,  148 

exophthalmic  goiter,  490 

facial  paralysis,  169 

fractures,  lower  jaw,  119 
skull,  36 

gunshot,  skull  and  brain,  39 

Hodgkin's  disease,  351 


Treatment,  infections,  face,  133 

inflammation,  salivary  glands,  231 

injuries,  larynx,  417 
trachea,  419 

Ludwig's  angina,  157,  323 

l3'mphangioma,  tongue,  214 

mastoiditis,  acute,  308 
chronic,  309 

middle  meningeal  hemorrhage,  48 

moles,  etc.,  13 

nevi,  scalp,  15 

orbital  abscess,  143 
tumors,  146 

otitis  media,  300 

Rigg's  disease,  158 

rodent  ulcer,  152 

salivary  fistulas,  229 

sarcinoma,  jaws,  160 

scalp  wounds,  8 

sinusitis,  281 

stomatitis,  183  el  seq. 

subdural  hemorrhage,  55 

tetany,  524 

thymus,  541,  542 

tic  douloureux,  167,  173 

tuberculosis,  tongue,  205 

tuberculous  adenitis,  neck   337 

tumor,  carotid  gland,  400 

tumors,  face,  139,  146  et  seq. 
larynx,  426 

venous  sinus,  hemorrhage,  50 

woundS;  brain,  58 

heart  and  pericardium,  547 
neck,  354,  355 
orbit,  141 
thoracic  duct,  356 
Trendelenburg.     Development,  lip,  80 
Trephining,  hemostasis,  65 

middle  meningeal  hemorrhage,  49 
Treves.     Dangerous  area,  scalp,  2 
Trichiniasis  muscles,  neck,  388 
Trifacial  nerve,  injuries,  34 

operations  on,  174 
Trigeminal  neuralgia,  165,  173 
Trousseau's  phenomena,  524 
Tubercles,  mandibular,  no 
Tuberculosis,  breast,  565 

face,  137 

glands,  neck,  333 

jaws,  156 

larynx,  421 

mouth,  189 


INDEX 


651 


Tuberculosis,  muscles,  neck,  387 

nose,  262 

oesophagus,  471 

pericardium,  555 

pharynx,  241 

salivary  glands,  233 

tongue,  204 
Tuberculous  ulcer,  scalp,  11 
Tuffnell.     Carotid  aneurism,  376 
Tumors,  benign,  breast,  581 

breast,  558 

indications,  operation,  618 

carotid  gland,  397 

disappearing,  breast,  579,  580 

external  ear,  297 

face,  139,  146  el  seq. 

jaws,  159 

operations  on,  177,  193 

larynx,  423,  426 

mouth,  191 

muscles,  neck,  389 

naso-pharynx,  273 

neck,  390 

nose,  266 

oesophagus,  472 

orbit,  144 

parathyroids,  522 

pharynx,  246 

Pott's  puffy,  60,  61 

salivary  glands,  233 

scalp,  II 

thyreoglossal  duct,  116 

thymus,  534,  54© 

tongue,  211 

trachea  and  bronchi,  425 
Turbinectomy,  256 
Tympanic  cavity  diseases,  299 
Tympanum,  incisions,  300 
Types  of  fractures,  skull,  28 
Typhoid,  larynx,  422 

nose,  262 


U 


Ulcer,  lip,  148 

malignant,  mouth,  192 

rodent,  151 

tongue,  215 

tuberculous,  scalp,  11 
Ulceration,  nipple,  573 
•       tongue,  203 
Unuateral  hypertrophy,  breast,  559 


Upper  jaw,  excision,  179 

Urachus,  74 

Uranoplasty,  98 

Urinary  bladder,  development,  74 

Urotropin,  fracture  skull,  37 


Vaccines,  Hodgkin's  disease,  352 

Rigg's  disease,  158 
Vagus  nerve,  injury,  357 
Valpeau's  incision,  180 
Vascular  supply,  scalp,  2 
Vaughan,  heart  and  pericardium,  352 
Vein,  axillary,  cancer  breast,  630 
Veins,  neck,  air  embolism,  355 

wounds,  355 
Venous  sinuses,  skull,  hemorrhage  49 
Vertebral  artery,  injuries,  371 
Vessels,  thyroid,  ligation,  491 
Virchow.     Fissure  angioma,  154 
Virginal  hj'pertroph}',  breast,  559 
Vogt.     Treatment,  thymus,  542 
Voice  after  goiter  operation,  506 

after  laryngeal  operation,  cancer,  429 
Vorschiitz's  pins,  65 


W 


Wahl.     Fracture,  skull,  24 
Wandering  rash,  tongue,  209 
Warinski.     Development,  lip,  82 
Warts,  lip,  148 

scalp,  13 

tongue,  215 
Weber.     Psychasthenia,  63 
Weber's  incision,  180 

Weissmann.     Middle    meningeal  hemor- 
rhage, 46 
Wens,  12 

Wharton.     Intracranial  hemorrhage,  50 
Wharton's  duct,  calculi,  231 
Wilms.     Rupture,  heart,  550 
Wilson.     Pathological  thyroid,  480,  490 

Pathology,  goiter,  505 

Pathology,  toxic  goiter,  501 
Wiring  aneurism,  375 
Wolfler.     Exophthalmic  goiter,  491 
Wood.    Lymphatics,  neck,  330 
Wool-sorter's  disease,  134 
Word-blindness,  54 

deafness,  54 


652 


INDEX 


Wounds,  brain,  57 

carotid  arteries,  368 

face,  130 

gunshot,  skull  and  brain,  37 

heart  and  pericardium,  545 

larynx,  418 

mouth,  195 

muscles,  neck,  388 

neck,  352 

orbit,  141 

salivary  glands,  227 

scalp,  3,  7 

skull,  27 

thoracic  duct,  356 

tongue,  197 


X 

X-ray,  diverticulum  oesophagus,  468 
exophthalmic  goiter,  491 
heart  wounds,  546 
moles,  scalp,  13 
nasal  disease,  279 
thymus,  539,  541 
tumors,  face,  146,  152 


Yates.     Hodgkin's  disease,  351 

Z 

Zesas.     Wounds,  thoracic  duct,  356 
Zygoma,  fracture,  124 


CoSlMjiilVERSlTY  LIBRARIES  |hsl  stK  i 

RD  31  B51  C.1  V.  1 

A  treatise  o'-r?n_n':ji;viwn;^,, 


200210hOoo 


NOV     '6i\i]k 


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